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KMA WELFARE BENEFITS PLAN 401k Plan overview

Plan NameKMA WELFARE BENEFITS PLAN
Plan identification number 501

KMA WELFARE BENEFITS 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)
  • Other welfare benefit cover

401k Sponsoring company profile

KUBOTA MANUFACTURING OF AMERICA CORPORATION has sponsored the creation of one or more 401k plans.

Company Name:KUBOTA MANUFACTURING OF AMERICA CORPORATION
Employer identification number (EIN):581781948
NAIC Classification:333100

Additional information about KUBOTA MANUFACTURING OF AMERICA CORPORATION

Jurisdiction of Incorporation: Georgia Department of States Corporations Division
Incorporation Date:
Company Identification Number: 747238

More information about KUBOTA MANUFACTURING OF AMERICA CORPORATION

Form 5500 Filing Information

Submission information for form 5500 for 401k plan KMA WELFARE BENEFITS 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
5012017-01-01PHIL SUTTON PHIL SUTTON2018-07-19
5012016-01-01PHIL SUTTON
5012015-01-01PHIL SUTTON
5012014-01-01PHIL SUTTON PHIL SUTTON2015-10-13
5012013-01-01JENNIFER POWELL PHIL SUTTON2014-09-16
5012012-01-01PHIL SUTTON PHIL SUTTON2013-10-04
5012011-01-01PHIL SUTTON
5012009-01-01PHILLIP SUTTON
5012009-01-01 PHILLIP SUTTON2010-07-14

Plan Statistics for KMA WELFARE BENEFITS PLAN

401k plan membership statisitcs for KMA WELFARE BENEFITS PLAN

Measure Date Value
2022: KMA WELFARE BENEFITS PLAN 2022 401k membership
Total participants, beginning-of-year2022-01-012,491
Total number of active participants reported on line 7a of the Form 55002022-01-013,040
Number of retired or separated participants receiving benefits2022-01-0117
Number of other retired or separated participants entitled to future benefits2022-01-010
Total of all active and inactive participants2022-01-013,057
2021: KMA WELFARE BENEFITS PLAN 2021 401k membership
Total participants, beginning-of-year2021-01-012,463
Total number of active participants reported on line 7a of the Form 55002021-01-012,471
Number of retired or separated participants receiving benefits2021-01-0120
Number of other retired or separated participants entitled to future benefits2021-01-010
Total of all active and inactive participants2021-01-012,491
2020: KMA WELFARE BENEFITS PLAN 2020 401k membership
Total participants, beginning-of-year2020-01-012,435
Total number of active participants reported on line 7a of the Form 55002020-01-012,457
Number of retired or separated participants receiving benefits2020-01-016
Number of other retired or separated participants entitled to future benefits2020-01-010
Total of all active and inactive participants2020-01-012,463
2019: KMA WELFARE BENEFITS PLAN 2019 401k membership
Total participants, beginning-of-year2019-01-012,334
Total number of active participants reported on line 7a of the Form 55002019-01-012,435
Number of retired or separated participants receiving benefits2019-01-010
Number of other retired or separated participants entitled to future benefits2019-01-010
Total of all active and inactive participants2019-01-012,435
2018: KMA WELFARE BENEFITS PLAN 2018 401k membership
Total participants, beginning-of-year2018-01-012,238
Total number of active participants reported on line 7a of the Form 55002018-01-012,331
Number of retired or separated participants receiving benefits2018-01-013
Number of other retired or separated participants entitled to future benefits2018-01-010
Total of all active and inactive participants2018-01-012,334
2017: KMA WELFARE BENEFITS PLAN 2017 401k membership
Total participants, beginning-of-year2017-01-012,054
Total number of active participants reported on line 7a of the Form 55002017-01-012,236
Number of retired or separated participants receiving benefits2017-01-012
Number of other retired or separated participants entitled to future benefits2017-01-010
Total of all active and inactive participants2017-01-012,238
2016: KMA WELFARE BENEFITS PLAN 2016 401k membership
Total participants, beginning-of-year2016-01-011,633
Total number of active participants reported on line 7a of the Form 55002016-01-012,054
Number of retired or separated participants receiving benefits2016-01-010
Number of other retired or separated participants entitled to future benefits2016-01-010
Total of all active and inactive participants2016-01-012,054
2015: KMA WELFARE BENEFITS PLAN 2015 401k membership
Total participants, beginning-of-year2015-01-013,517
Total number of active participants reported on line 7a of the Form 55002015-01-011,633
Number of retired or separated participants receiving benefits2015-01-010
Number of other retired or separated participants entitled to future benefits2015-01-010
Total of all active and inactive participants2015-01-011,633
2014: KMA WELFARE BENEFITS PLAN 2014 401k membership
Total participants, beginning-of-year2014-01-013,243
Total number of active participants reported on line 7a of the Form 55002014-01-013,513
Number of retired or separated participants receiving benefits2014-01-014
Number of other retired or separated participants entitled to future benefits2014-01-010
Total of all active and inactive participants2014-01-013,517
2013: KMA WELFARE BENEFITS PLAN 2013 401k membership
Total participants, beginning-of-year2013-01-012,736
Total number of active participants reported on line 7a of the Form 55002013-01-013,233
Number of retired or separated participants receiving benefits2013-01-0110
Number of other retired or separated participants entitled to future benefits2013-01-010
Total of all active and inactive participants2013-01-013,243
2012: KMA WELFARE BENEFITS PLAN 2012 401k membership
Total participants, beginning-of-year2012-01-012,642
Total number of active participants reported on line 7a of the Form 55002012-01-012,718
Number of retired or separated participants receiving benefits2012-01-019
Number of other retired or separated participants entitled to future benefits2012-01-010
Total of all active and inactive participants2012-01-012,727
2011: KMA WELFARE BENEFITS PLAN 2011 401k membership
Total participants, beginning-of-year2011-01-012,539
Total number of active participants reported on line 7a of the Form 55002011-01-012,634
Number of retired or separated participants receiving benefits2011-01-018
Number of other retired or separated participants entitled to future benefits2011-01-010
Total of all active and inactive participants2011-01-012,642
2009: KMA WELFARE BENEFITS PLAN 2009 401k membership
Total participants, beginning-of-year2009-01-011,032
Total number of active participants reported on line 7a of the Form 55002009-01-011,022
Number of retired or separated participants receiving benefits2009-01-0110
Number of other retired or separated participants entitled to future benefits2009-01-010
Total of all active and inactive participants2009-01-011,032
Total participants2009-01-011,032

Form 5500 Responses for KMA WELFARE BENEFITS PLAN

2022: KMA WELFARE BENEFITS PLAN 2022 form 5500 responses
2022-01-01Type of plan entitySingle employer plan
2022-01-01Submission has been amendedNo
2022-01-01This submission is the final filingNo
2022-01-01This return/report is a short plan year return/report (less than 12 months)No
2022-01-01Plan is a collectively bargained planNo
2022-01-01Plan funding arrangement – InsuranceYes
2022-01-01Plan funding arrangement – General assets of the sponsorYes
2022-01-01Plan benefit arrangement – InsuranceYes
2022-01-01Plan benefit arrangement – General assets of the sponsorYes
2021: KMA WELFARE BENEFITS PLAN 2021 form 5500 responses
2021-01-01Type of plan entitySingle employer plan
2021-01-01Submission has been amendedNo
2021-01-01This submission is the final filingNo
2021-01-01This return/report is a short plan year return/report (less than 12 months)No
2021-01-01Plan is a collectively bargained planNo
2021-01-01Plan funding arrangement – InsuranceYes
2021-01-01Plan funding arrangement – General assets of the sponsorYes
2021-01-01Plan benefit arrangement – InsuranceYes
2021-01-01Plan benefit arrangement – General assets of the sponsorYes
2020: KMA WELFARE BENEFITS PLAN 2020 form 5500 responses
2020-01-01Type of plan entitySingle employer plan
2020-01-01Submission has been amendedNo
2020-01-01This submission is the final filingNo
2020-01-01This return/report is a short plan year return/report (less than 12 months)No
2020-01-01Plan is a collectively bargained planNo
2020-01-01Plan funding arrangement – InsuranceYes
2020-01-01Plan funding arrangement – General assets of the sponsorYes
2020-01-01Plan benefit arrangement – InsuranceYes
2020-01-01Plan benefit arrangement – General assets of the sponsorYes
2019: KMA WELFARE BENEFITS PLAN 2019 form 5500 responses
2019-01-01Type of plan entitySingle employer plan
2019-01-01Submission has been amendedNo
2019-01-01This submission is the final filingNo
2019-01-01This return/report is a short plan year return/report (less than 12 months)No
2019-01-01Plan is a collectively bargained planNo
2019-01-01Plan funding arrangement – InsuranceYes
2019-01-01Plan funding arrangement – General assets of the sponsorYes
2019-01-01Plan benefit arrangement – InsuranceYes
2019-01-01Plan benefit arrangement – General assets of the sponsorYes
2018: KMA WELFARE BENEFITS PLAN 2018 form 5500 responses
2018-01-01Type of plan entitySingle employer plan
2018-01-01Submission has been amendedNo
2018-01-01This submission is the final filingNo
2018-01-01This return/report is a short plan year return/report (less than 12 months)No
2018-01-01Plan is a collectively bargained planNo
2018-01-01Plan funding arrangement – InsuranceYes
2018-01-01Plan funding arrangement – General assets of the sponsorYes
2018-01-01Plan benefit arrangement – InsuranceYes
2018-01-01Plan benefit arrangement – General assets of the sponsorYes
2017: KMA WELFARE BENEFITS PLAN 2017 form 5500 responses
2017-01-01Type of plan entitySingle employer plan
2017-01-01Submission has been amendedNo
2017-01-01This submission is the final filingNo
2017-01-01This return/report is a short plan year return/report (less than 12 months)No
2017-01-01Plan is a collectively bargained planNo
2017-01-01Plan funding arrangement – InsuranceYes
2017-01-01Plan funding arrangement – General assets of the sponsorYes
2017-01-01Plan benefit arrangement – InsuranceYes
2017-01-01Plan benefit arrangement – General assets of the sponsorYes
2016: KMA WELFARE BENEFITS PLAN 2016 form 5500 responses
2016-01-01Type of plan entitySingle employer plan
2016-01-01Submission has been amendedNo
2016-01-01This submission is the final filingNo
2016-01-01This return/report is a short plan year return/report (less than 12 months)No
2016-01-01Plan is a collectively bargained planNo
2016-01-01Plan funding arrangement – InsuranceYes
2016-01-01Plan funding arrangement – General assets of the sponsorYes
2016-01-01Plan benefit arrangement – InsuranceYes
2016-01-01Plan benefit arrangement – General assets of the sponsorYes
2015: KMA WELFARE BENEFITS PLAN 2015 form 5500 responses
2015-01-01Type of plan entitySingle employer plan
2015-01-01Submission has been amendedNo
2015-01-01This submission is the final filingNo
2015-01-01This return/report is a short plan year return/report (less than 12 months)No
2015-01-01Plan is a collectively bargained planNo
2015-01-01Plan funding arrangement – InsuranceYes
2015-01-01Plan funding arrangement – General assets of the sponsorYes
2015-01-01Plan benefit arrangement – InsuranceYes
2015-01-01Plan benefit arrangement – General assets of the sponsorYes
2014: KMA WELFARE BENEFITS PLAN 2014 form 5500 responses
2014-01-01Type of plan entitySingle employer plan
2014-01-01Submission has been amendedNo
2014-01-01This submission is the final filingNo
2014-01-01This return/report is a short plan year return/report (less than 12 months)No
2014-01-01Plan is a collectively bargained planNo
2014-01-01Plan funding arrangement – InsuranceYes
2014-01-01Plan funding arrangement – General assets of the sponsorYes
2014-01-01Plan benefit arrangement – InsuranceYes
2014-01-01Plan benefit arrangement – General assets of the sponsorYes
2013: KMA WELFARE BENEFITS PLAN 2013 form 5500 responses
2013-01-01Type of plan entitySingle employer plan
2013-01-01Submission has been amendedNo
2013-01-01This submission is the final filingNo
2013-01-01This return/report is a short plan year return/report (less than 12 months)No
2013-01-01Plan is a collectively bargained planNo
2013-01-01Plan funding arrangement – InsuranceYes
2013-01-01Plan funding arrangement – General assets of the sponsorYes
2013-01-01Plan benefit arrangement – InsuranceYes
2013-01-01Plan benefit arrangement – General assets of the sponsorYes
2012: KMA WELFARE BENEFITS PLAN 2012 form 5500 responses
2012-01-01Type of plan entitySingle employer plan
2012-01-01Submission has been amendedNo
2012-01-01This submission is the final filingNo
2012-01-01This return/report is a short plan year return/report (less than 12 months)No
2012-01-01Plan is a collectively bargained planNo
2012-01-01Plan funding arrangement – InsuranceYes
2012-01-01Plan funding arrangement – General assets of the sponsorYes
2012-01-01Plan benefit arrangement – InsuranceYes
2012-01-01Plan benefit arrangement – General assets of the sponsorYes
2011: KMA WELFARE BENEFITS PLAN 2011 form 5500 responses
2011-01-01Type of plan entitySingle employer plan
2011-01-01Submission has been amendedNo
2011-01-01This submission is the final filingNo
2011-01-01This return/report is a short plan year return/report (less than 12 months)No
2011-01-01Plan is a collectively bargained planNo
2011-01-01Plan funding arrangement – InsuranceYes
2011-01-01Plan funding arrangement – General assets of the sponsorYes
2011-01-01Plan benefit arrangement – InsuranceYes
2011-01-01Plan benefit arrangement – General assets of the sponsorYes
2009: KMA WELFARE BENEFITS PLAN 2009 form 5500 responses
2009-01-01Type of plan entitySingle employer plan
2009-01-01Submission has been amendedYes
2009-01-01This submission is the final filingNo
2009-01-01This return/report is a short plan year return/report (less than 12 months)No
2009-01-01Plan is a collectively bargained planNo
2009-01-01Plan funding arrangement – InsuranceYes
2009-01-01Plan 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

CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number2501685
Policy instance 5
Insurance contract or identification number2501685
Number of Individuals Covered173
Insurance policy start date2022-05-01
Insurance policy end date2022-12-31
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $4,871
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number3343034/2501280
Policy instance 4
Insurance contract or identification number3343034/2501280
Number of Individuals Covered5940246
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $39,749
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $276,414
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $24,621
Insurance broker organization code?3
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract numberGF3890LF027001
Policy instance 3
Insurance contract or identification numberGF3890LF027001
Number of Individuals Covered3171
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $69,207
Total amount of fees paid to insurance companyUSD $4,035
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $477,411
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $44,875
Insurance broker organization code?3
Amount paid for insurance broker fees4035
Additional information about fees paid to insurance brokerSUPPLEMENTAL COMPENSATION
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract numberSA3890LF027001
Policy instance 2
Insurance contract or identification numberSA3890LF027001
Number of Individuals Covered3170
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $65,546
Total amount of fees paid to insurance companyUSD $5,319
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $600,159
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $40,587
Insurance broker organization code?3
Amount paid for insurance broker fees5319
Additional information about fees paid to insurance brokerSUPPLEMENTAL COMPENSATION
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract numberGD3890LF027001
Policy instance 1
Insurance contract or identification numberGD3890LF027001
Number of Individuals Covered3171
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $30,856
Total amount of fees paid to insurance companyUSD $4,603
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $539,815
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $30,856
Amount paid for insurance broker fees4603
Additional information about fees paid to insurance brokerSUPPLEMENTAL COMPENSATION
Insurance broker organization code?3
LIBERTY LIFE ASSURANCE COMPANY OF BOSTON (National Association of Insurance Commissioners NAIC id number: 65315 )
Policy contract numberSA3890LF027001
Policy instance 1
Insurance contract or identification numberSA3890LF027001
Number of Individuals Covered2471
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $42,956
Total amount of fees paid to insurance companyUSD $8,980
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $378,448
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $42,956
Amount paid for insurance broker fees8980
Additional information about fees paid to insurance brokerSUPPLEMENTAL COMPENSATION
Insurance broker organization code?3
LIBERTY LIFE ASSURANCE COMPANY OF BOSTON (National Association of Insurance Commissioners NAIC id number: 65315 )
Policy contract numberGF3890LF027001
Policy instance 2
Insurance contract or identification numberGF3890LF027001
Number of Individuals Covered2389
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $45,958
Total amount of fees paid to insurance companyUSD $7,108
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $296,171
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $45,958
Amount paid for insurance broker fees7108
Additional information about fees paid to insurance brokerSUPPLEMENTAL COMPENSATION
Insurance broker organization code?3
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number3343034
Policy instance 3
Insurance contract or identification number3343034
Number of Individuals Covered5191
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $3,458
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $254,850
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,458
Insurance broker organization code?3
LIBERTY LIFE ASSURANCE COMPANY OF BOSTON (National Association of Insurance Commissioners NAIC id number: 65315 )
Policy contract numberGD3890LF027001
Policy instance 4
Insurance contract or identification numberGD3890LF027001
Number of Individuals Covered3315
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $32,042
Total amount of fees paid to insurance companyUSD $8,107
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $338,372
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $32,042
Amount paid for insurance broker fees8107
Additional information about fees paid to insurance brokerSUPPLEMENTAL COMPENSATION
Insurance broker organization code?3
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number3343034
Policy instance 4
Insurance contract or identification number3343034
Number of Individuals Covered4010
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $36,937
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $246,241
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $36,937
Insurance broker organization code?3
LIBERTY LIFE ASSURANCE COMPANY OF BOSTON (National Association of Insurance Commissioners NAIC id number: 65315 )
Policy contract numberSA3890LF027001
Policy instance 3
Insurance contract or identification numberSA3890LF027001
Number of Individuals Covered946
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $40,325
Total amount of fees paid to insurance companyUSD $7,652
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $374,500
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $40,325
Amount paid for insurance broker fees2705
Additional information about fees paid to insurance brokerSUPPLEMENTAL COMPENSATION
Insurance broker organization code?3
LIBERTY LIFE ASSURANCE COMPANY OF BOSTON (National Association of Insurance Commissioners NAIC id number: 65315 )
Policy contract numberGF3890LF027001
Policy instance 2
Insurance contract or identification numberGF3890LF027001
Number of Individuals Covered923
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $43,469
Total amount of fees paid to insurance companyUSD $4,443
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $300,007
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $43,469
Amount paid for insurance broker fees2129
Additional information about fees paid to insurance brokerSUPPLEMENTAL COMPENSATION
Insurance broker organization code?3
LIBERTY LIFE ASSURANCE COMPANY OF BOSTON (National Association of Insurance Commissioners NAIC id number: 65315 )
Policy contract numberGD3890LF027001
Policy instance 1
Insurance contract or identification numberGD3890LF027001
Number of Individuals Covered1250
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $30,252
Total amount of fees paid to insurance companyUSD $5,073
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $341,700
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $30,252
Amount paid for insurance broker fees2434
Additional information about fees paid to insurance brokerSUPPLEMENTAL COMPENSATION
Insurance broker organization code?3
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number0166448
Policy instance 2
Insurance contract or identification number0166448
Number of Individuals Covered4097
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $116,386
Total amount of fees paid to insurance companyUSD $14,901
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $971,905
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $116,386
Amount paid for insurance broker fees14901
Additional information about fees paid to insurance brokerNON-MONETARY COMPENSATION, SUPPLEMENTAL COMPENSATION & OTHER
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 numberGA7780
Policy instance 1
Insurance contract or identification numberGA7780
Number of Individuals Covered3865
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $237,743
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 number0166448
Policy instance 2
Insurance contract or identification number0166448
Number of Individuals Covered3771
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $87,929
Total amount of fees paid to insurance companyUSD $21,128
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $801,416
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $87,929
Amount paid for insurance broker fees159
Additional information about fees paid to insurance brokerNON-MONETARY COMPENSATION
Insurance broker organization code?3
Insurance broker nameAON CONSULTING
BLUE CROSS AND BLUE SHIELD OF GEORGIA, INC/ (G0385) (National Association of Insurance Commissioners NAIC id number: 54801 )
Policy contract numberGA7780
Policy instance 1
Insurance contract or identification numberGA7780
Number of Individuals Covered3353
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $53,064
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $161,981
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $34,711
Insurance broker organization code?3
Insurance broker nameAON CONSULTING
BLUE CROSS AND BLUE SHIELD OF GEORGIA, INC/ (G0385) (National Association of Insurance Commissioners NAIC id number: 54801 )
Policy contract numberGA7780
Policy instance 2
Insurance contract or identification numberGA7780
Number of Individuals Covered2329
Insurance policy start date2015-01-01
Insurance policy end date2015-12-31
Total amount of commissions paid to insurance brokerUSD $4,877
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $140,718
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,877
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameAON CONSULTING
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number51872
Policy instance 1
Insurance contract or identification number51872
Number of Individuals Covered1687
Insurance policy start date2015-01-01
Insurance policy end date2015-12-31
Total amount of commissions paid to insurance brokerUSD $61,661
Total amount of fees paid to insurance companyUSD $845
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH & DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $532,568
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $61,661
Amount paid for insurance broker fees845
Additional information about fees paid to insurance brokerSUPPLEMENTAL COMMISSION
Insurance broker organization code?3
Insurance broker nameAON CONSULTING INC
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number51872
Policy instance 1
Insurance contract or identification number51872
Number of Individuals Covered1065
Insurance policy start date2014-10-01
Insurance policy end date2014-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH & DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $87,050
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number90690
Policy instance 2
Insurance contract or identification number90690
Number of Individuals Covered1021
Insurance policy start date2014-01-01
Insurance policy end date2014-09-30
Total amount of commissions paid to insurance brokerUSD $28,535
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH & DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $246,927
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $28,535
Insurance broker organization code?3
Insurance broker nameAON CONSULTING INC.
BLUE CROSS AND BLUE SHIELD OF GEORGIA, INC/ (G0385) (National Association of Insurance Commissioners NAIC id number: 54801 )
Policy contract numberGA7780
Policy instance 3
Insurance contract or identification numberGA7780
Number of Individuals Covered1458
Insurance policy start date2014-01-01
Insurance policy end date2014-12-31
Total amount of commissions paid to insurance brokerUSD $2,508
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $205,728
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,508
Insurance broker organization code?3
Insurance broker nameAON CONSULTING
BLUE CROSS AND BLUE SHIELD OF GEORGIA, INC/ (G0385) (National Association of Insurance Commissioners NAIC id number: 54801 )
Policy contract numberGA7780
Policy instance 2
Insurance contract or identification numberGA7780
Number of Individuals Covered725
Insurance policy start date2013-01-01
Insurance policy end date2013-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $85,108
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number90690
Policy instance 1
Insurance contract or identification number90690
Number of Individuals Covered1284
Insurance policy start date2013-01-01
Insurance policy end date2013-12-31
Total amount of commissions paid to insurance brokerUSD $38,590
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&D
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $351,684
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $38,590
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameAON CONSULTING INC
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number90690
Policy instance 2
Insurance contract or identification number90690
Number of Individuals Covered1094
Insurance policy start date2012-01-01
Insurance policy end date2012-12-31
Total amount of commissions paid to insurance brokerUSD $43,913
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&D
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $340,876
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $38,277
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameAON CONSULTING, INC.
BLUE CROSS AND BLUE SHIELD OF GEORGIA, INC/ (G0385) (National Association of Insurance Commissioners NAIC id number: 54801 )
Policy contract number1050791000
Policy instance 1
Insurance contract or identification number1050791000
Number of Individuals Covered1133
Insurance policy start date2012-01-01
Insurance policy end date2012-12-31
Total amount of commissions paid to insurance brokerUSD $9,148
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $70,100
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $9,148
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameAON CONSULTING, INC.
BLUE CROSS AND BLUE SHIELD OF GEORGIA, INC/ (G0385) (National Association of Insurance Commissioners NAIC id number: 54801 )
Policy contract number1050791000
Policy instance 1
Insurance contract or identification number1050791000
Number of Individuals Covered1072
Insurance policy start date2011-01-01
Insurance policy end date2011-12-31
Total amount of commissions paid to insurance brokerUSD $7,379
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $61,732
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number90690
Policy instance 2
Insurance contract or identification number90690
Number of Individuals Covered1043
Insurance policy start date2011-01-01
Insurance policy end date2011-12-31
Total amount of commissions paid to insurance brokerUSD $39,127
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH & DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $320,445
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number90690
Policy instance 1
Insurance contract or identification number90690
Number of Individuals Covered966
Insurance policy start date2010-01-01
Insurance policy end date2010-12-31
Total amount of commissions paid to insurance brokerUSD $38,879
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $315,623
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No

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