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MAXXIS INTERNATIONAL USA WELFARE BENEFIT PLAN 401k Plan overview

Plan NameMAXXIS INTERNATIONAL USA WELFARE BENEFIT PLAN
Plan identification number 501

MAXXIS INTERNATIONAL USA 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)
  • Other welfare benefit cover

401k Sponsoring company profile

CHENG SHIN RUBBER USA INC. D/B/A MAXXIS INTERNAT has sponsored the creation of one or more 401k plans.

Company Name:CHENG SHIN RUBBER USA INC. D/B/A MAXXIS INTERNAT
Employer identification number (EIN):581892851
NAIC Classification:423990
NAIC Description:Other Miscellaneous Durable Goods Merchant Wholesalers

Form 5500 Filing Information

Submission information for form 5500 for 401k plan MAXXIS INTERNATIONAL USA WELFARE BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5012021-07-01KELLIE CARTER2023-03-24
5012020-07-01
5012019-07-01
5012018-07-01
5012017-07-01KELLIE CARTER
5012016-07-01KELLIE CARTER
5012015-07-01KELLIE CARTER
5012014-07-01KELLIE CARTER
5012013-07-01KELLIE CARTER
5012012-07-01KELLIE CARTER
5012011-07-01KELLIE CARTER
5012010-07-01KELLIE CARTER

Plan Statistics for MAXXIS INTERNATIONAL USA WELFARE BENEFIT PLAN

401k plan membership statisitcs for MAXXIS INTERNATIONAL USA WELFARE BENEFIT PLAN

Measure Date Value
2021: MAXXIS INTERNATIONAL USA WELFARE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year2021-07-01163
Total number of active participants reported on line 7a of the Form 55002021-07-01169
Number of retired or separated participants receiving benefits2021-07-010
Number of other retired or separated participants entitled to future benefits2021-07-010
Total of all active and inactive participants2021-07-01169
Number of employers contributing to the scheme2021-07-010
2020: MAXXIS INTERNATIONAL USA WELFARE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year2020-07-01137
Total number of active participants reported on line 7a of the Form 55002020-07-01162
Number of retired or separated participants receiving benefits2020-07-011
Total of all active and inactive participants2020-07-01163
2019: MAXXIS INTERNATIONAL USA WELFARE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year2019-07-01137
Total number of active participants reported on line 7a of the Form 55002019-07-01156
Total of all active and inactive participants2019-07-01156
2018: MAXXIS INTERNATIONAL USA WELFARE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year2018-07-01135
Total number of active participants reported on line 7a of the Form 55002018-07-01137
Total of all active and inactive participants2018-07-01137
2017: MAXXIS INTERNATIONAL USA WELFARE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year2017-07-01135
Total number of active participants reported on line 7a of the Form 55002017-07-01140
Total of all active and inactive participants2017-07-01140
2016: MAXXIS INTERNATIONAL USA WELFARE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year2016-07-01121
Total number of active participants reported on line 7a of the Form 55002016-07-01135
Total of all active and inactive participants2016-07-01135
2015: MAXXIS INTERNATIONAL USA WELFARE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year2015-07-01117
Total number of active participants reported on line 7a of the Form 55002015-07-01121
Total of all active and inactive participants2015-07-01121
2014: MAXXIS INTERNATIONAL USA WELFARE BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year2014-07-01118
Total number of active participants reported on line 7a of the Form 55002014-07-01117
Total of all active and inactive participants2014-07-01117
2013: MAXXIS INTERNATIONAL USA WELFARE BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year2013-07-01112
Total number of active participants reported on line 7a of the Form 55002013-07-01118
Total of all active and inactive participants2013-07-01118
2012: MAXXIS INTERNATIONAL USA WELFARE BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year2012-07-01111
Total number of active participants reported on line 7a of the Form 55002012-07-01112
Total of all active and inactive participants2012-07-01112
2011: MAXXIS INTERNATIONAL USA WELFARE BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year2011-07-01109
Total number of active participants reported on line 7a of the Form 55002011-07-01111
Total of all active and inactive participants2011-07-01111
2010: MAXXIS INTERNATIONAL USA WELFARE BENEFIT PLAN 2010 401k membership
Total participants, beginning-of-year2010-07-01169
Total number of active participants reported on line 7a of the Form 55002010-07-01109
Total of all active and inactive participants2010-07-01109

Form 5500 Responses for MAXXIS INTERNATIONAL USA WELFARE BENEFIT PLAN

2021: MAXXIS INTERNATIONAL USA WELFARE BENEFIT PLAN 2021 form 5500 responses
2021-07-01Type of plan entitySingle employer plan
2021-07-01Plan funding arrangement – InsuranceYes
2021-07-01Plan funding arrangement – General assets of the sponsorYes
2021-07-01Plan benefit arrangement – InsuranceYes
2021-07-01Plan benefit arrangement – General assets of the sponsorYes
2020: MAXXIS INTERNATIONAL USA WELFARE BENEFIT PLAN 2020 form 5500 responses
2020-07-01Type of plan entitySingle employer plan
2020-07-01Submission has been amendedNo
2020-07-01This submission is the final filingNo
2020-07-01This return/report is a short plan year return/report (less than 12 months)No
2020-07-01Plan is a collectively bargained planNo
2020-07-01Plan funding arrangement – InsuranceYes
2020-07-01Plan benefit arrangement – InsuranceYes
2019: MAXXIS INTERNATIONAL USA WELFARE BENEFIT PLAN 2019 form 5500 responses
2019-07-01Type of plan entitySingle employer plan
2019-07-01Submission has been amendedNo
2019-07-01This submission is the final filingNo
2019-07-01This return/report is a short plan year return/report (less than 12 months)No
2019-07-01Plan is a collectively bargained planNo
2019-07-01Plan funding arrangement – InsuranceYes
2019-07-01Plan benefit arrangement – InsuranceYes
2018: MAXXIS INTERNATIONAL USA WELFARE BENEFIT PLAN 2018 form 5500 responses
2018-07-01Type of plan entitySingle employer plan
2018-07-01Submission has been amendedNo
2018-07-01This submission is the final filingNo
2018-07-01This return/report is a short plan year return/report (less than 12 months)No
2018-07-01Plan is a collectively bargained planNo
2018-07-01Plan funding arrangement – InsuranceYes
2018-07-01Plan benefit arrangement – InsuranceYes
2017: MAXXIS INTERNATIONAL USA WELFARE BENEFIT PLAN 2017 form 5500 responses
2017-07-01Type of plan entitySingle employer plan
2017-07-01Submission has been amendedNo
2017-07-01This submission is the final filingNo
2017-07-01This return/report is a short plan year return/report (less than 12 months)No
2017-07-01Plan is a collectively bargained planNo
2017-07-01Plan funding arrangement – InsuranceYes
2017-07-01Plan benefit arrangement – InsuranceYes
2016: MAXXIS INTERNATIONAL USA WELFARE BENEFIT PLAN 2016 form 5500 responses
2016-07-01Type of plan entitySingle employer plan
2016-07-01Submission has been amendedNo
2016-07-01This submission is the final filingNo
2016-07-01This return/report is a short plan year return/report (less than 12 months)No
2016-07-01Plan is a collectively bargained planNo
2016-07-01Plan funding arrangement – InsuranceYes
2016-07-01Plan benefit arrangement – InsuranceYes
2015: MAXXIS INTERNATIONAL USA WELFARE BENEFIT PLAN 2015 form 5500 responses
2015-07-01Type of plan entitySingle employer plan
2015-07-01Submission has been amendedNo
2015-07-01This submission is the final filingNo
2015-07-01This return/report is a short plan year return/report (less than 12 months)No
2015-07-01Plan is a collectively bargained planNo
2015-07-01Plan funding arrangement – InsuranceYes
2015-07-01Plan benefit arrangement – InsuranceYes
2014: MAXXIS INTERNATIONAL USA WELFARE BENEFIT PLAN 2014 form 5500 responses
2014-07-01Type of plan entitySingle employer plan
2014-07-01Submission has been amendedNo
2014-07-01This submission is the final filingNo
2014-07-01This return/report is a short plan year return/report (less than 12 months)No
2014-07-01Plan is a collectively bargained planNo
2014-07-01Plan funding arrangement – InsuranceYes
2014-07-01Plan benefit arrangement – InsuranceYes
2013: MAXXIS INTERNATIONAL USA WELFARE BENEFIT PLAN 2013 form 5500 responses
2013-07-01Type of plan entitySingle employer plan
2013-07-01Submission has been amendedNo
2013-07-01This submission is the final filingNo
2013-07-01This return/report is a short plan year return/report (less than 12 months)No
2013-07-01Plan is a collectively bargained planNo
2013-07-01Plan funding arrangement – InsuranceYes
2013-07-01Plan benefit arrangement – InsuranceYes
2012: MAXXIS INTERNATIONAL USA WELFARE BENEFIT PLAN 2012 form 5500 responses
2012-07-01Type of plan entitySingle employer plan
2012-07-01Submission has been amendedNo
2012-07-01This submission is the final filingNo
2012-07-01This return/report is a short plan year return/report (less than 12 months)No
2012-07-01Plan is a collectively bargained planNo
2012-07-01Plan funding arrangement – InsuranceYes
2012-07-01Plan benefit arrangement – InsuranceYes
2011: MAXXIS INTERNATIONAL USA WELFARE BENEFIT PLAN 2011 form 5500 responses
2011-07-01Type of plan entitySingle employer plan
2011-07-01Submission has been amendedNo
2011-07-01This submission is the final filingNo
2011-07-01This return/report is a short plan year return/report (less than 12 months)No
2011-07-01Plan is a collectively bargained planNo
2011-07-01Plan funding arrangement – InsuranceYes
2011-07-01Plan benefit arrangement – InsuranceYes
2010: MAXXIS INTERNATIONAL USA WELFARE BENEFIT PLAN 2010 form 5500 responses
2010-07-01Type of plan entitySingle employer plan
2010-07-01Submission has been amendedNo
2010-07-01This submission is the final filingNo
2010-07-01This return/report is a short plan year return/report (less than 12 months)No
2010-07-01Plan is a collectively bargained planNo
2010-07-01Plan funding arrangement – InsuranceYes
2010-07-01Plan benefit arrangement – InsuranceYes

Insurance Providers Used on plan

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberSGM611148
Policy instance 2
Insurance contract or identification numberSGM611148
Number of Individuals Covered160
Insurance policy start date2022-07-01
Insurance policy end date2023-06-30
Total amount of commissions paid to insurance brokerUSD $14,771
Total amount of fees paid to insurance companyUSD $2,954
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
Welfare Benefit Premiums Paid to CarrierUSD $90,911
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $14,771
Amount paid for insurance broker fees2954
Additional information about fees paid to insurance brokerSERVICE FEES
Insurance broker organization code?3
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number629791
Policy instance 1
Insurance contract or identification number629791
Number of Individuals Covered216
Insurance policy start date2022-07-01
Insurance policy end date2023-06-30
Total amount of commissions paid to insurance brokerUSD $12,617
Total amount of fees paid to insurance companyUSD $51,736
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,914,305
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $12,617
Amount paid for insurance broker fees51736
Additional information about fees paid to insurance brokerBENEFIT ADVIOR FEES, SERVICE/GENERAL AGENT FEES
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberSGM611148
Policy instance 2
Insurance contract or identification numberSGM611148
Number of Individuals Covered169
Insurance policy start date2021-07-01
Insurance policy end date2022-06-30
Total amount of commissions paid to insurance brokerUSD $13,430
Total amount of fees paid to insurance companyUSD $2,686
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
Welfare Benefit Premiums Paid to CarrierUSD $89,918
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $13,430
Amount paid for insurance broker fees2686
Additional information about fees paid to insurance brokerSERVICE FEES
Insurance broker organization code?3
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number629791
Policy instance 1
Insurance contract or identification number629791
Number of Individuals Covered221
Insurance policy start date2021-07-01
Insurance policy end date2022-06-30
Total amount of commissions paid to insurance brokerUSD $12,579
Total amount of fees paid to insurance companyUSD $61,054
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,849,285
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $12,579
Amount paid for insurance broker fees61054
Additional information about fees paid to insurance brokerBENEFIT ADVISOR FEE, SERVICE/ GENERAL AGENT FEE, INCENTIVE COMPENSATION
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberSOK608310
Policy instance 1
Insurance contract or identification numberSOK608310
Number of Individuals Covered161
Insurance policy start date2020-07-01
Insurance policy end date2021-06-30
Total amount of commissions paid to insurance brokerUSD $668
Total amount of fees paid to insurance companyUSD $134
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $4,861
Commission paid to Insurance BrokerUSD $668
Amount paid for insurance broker fees134
Additional information about fees paid to insurance brokerBONUS
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberSGD612293
Policy instance 2
Insurance contract or identification numberSGD612293
Number of Individuals Covered162
Insurance policy start date2020-07-01
Insurance policy end date2021-06-30
Total amount of commissions paid to insurance brokerUSD $4,066
Total amount of fees paid to insurance companyUSD $813
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $29,654
Commission paid to Insurance BrokerUSD $4,066
Amount paid for insurance broker fees813
Additional information about fees paid to insurance brokerBONUS
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberSGM611148
Policy instance 3
Insurance contract or identification numberSGM611148
Number of Individuals Covered161
Insurance policy start date2020-07-01
Insurance policy end date2021-06-30
Total amount of commissions paid to insurance brokerUSD $3,979
Total amount of fees paid to insurance companyUSD $796
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $28,787
Commission paid to Insurance BrokerUSD $3,797
Amount paid for insurance broker fees796
Additional information about fees paid to insurance brokerBONUS
Insurance broker organization code?3
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number629791
Policy instance 4
Insurance contract or identification number629791
Number of Individuals Covered216
Insurance policy start date2020-07-01
Insurance policy end date2021-06-30
Total amount of commissions paid to insurance brokerUSD $11,844
Total amount of fees paid to insurance companyUSD $49,427
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,729,188
Commission paid to Insurance BrokerUSD $11,844
Amount paid for insurance broker fees47303
Additional information about fees paid to insurance brokerBENEFIT ADVISOR FEE
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberVDT602933
Policy instance 5
Insurance contract or identification numberVDT602933
Number of Individuals Covered76
Insurance policy start date2020-07-01
Insurance policy end date2021-06-30
Total amount of commissions paid to insurance brokerUSD $3,276
Total amount of fees paid to insurance companyUSD $655
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $23,801
Commission paid to Insurance BrokerUSD $3,276
Amount paid for insurance broker fees655
Additional information about fees paid to insurance brokerBONUS
Insurance broker organization code?3
BLUE CROSS BLUE SHIELD OF GEORGIA INC. (G0386) (National Association of Insurance Commissioners NAIC id number: 96962 )
Policy contract numberGA6072
Policy instance 2
Insurance contract or identification numberGA6072
Number of Individuals Covered157
Insurance policy start date2019-07-01
Insurance policy end date2020-06-30
Total amount of commissions paid to insurance brokerUSD $64,394
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,987,765
Commission paid to Insurance BrokerUSD $-64
Insurance broker organization code?3
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number21059
Policy instance 1
Insurance contract or identification number21059
Number of Individuals Covered156
Insurance policy start date2019-07-01
Insurance policy end date2020-06-30
Total amount of commissions paid to insurance brokerUSD $18,304
Total amount of fees paid to insurance companyUSD $0
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $82,266
Commission paid to Insurance BrokerUSD $18,304
Insurance broker organization code?3
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number21059
Policy instance 1
Insurance contract or identification number21059
Number of Individuals Covered137
Insurance policy start date2018-07-01
Insurance policy end date2019-06-30
Total amount of commissions paid to insurance brokerUSD $12,463
Total amount of fees paid to insurance companyUSD $0
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $83,087
Commission paid to Insurance BrokerUSD $12,463
Insurance broker organization code?3
BLUE CROSS BLUE SHIELD OF GEORGIA INC. (G0386) (National Association of Insurance Commissioners NAIC id number: 96962 )
Policy contract numberGA6072
Policy instance 2
Insurance contract or identification numberGA6072
Number of Individuals Covered139
Insurance policy start date2018-07-01
Insurance policy end date2019-06-30
Total amount of commissions paid to insurance brokerUSD $53,913
Total amount of fees paid to insurance companyUSD $764
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,695,390
Commission paid to Insurance BrokerUSD $53,913
Amount paid for insurance broker fees764
Additional information about fees paid to insurance brokerBONUS
Insurance broker organization code?3
BLUE CROSS BLUE SHIELD OF GEORGIA INC. (G0386) (National Association of Insurance Commissioners NAIC id number: 96962 )
Policy contract numberGA6072
Policy instance 2
Insurance contract or identification numberGA6072
Number of Individuals Covered240
Insurance policy start date2017-07-01
Insurance policy end date2018-06-30
Total amount of commissions paid to insurance brokerUSD $57,604
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,550,510
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number21059
Policy instance 1
Insurance contract or identification number21059
Number of Individuals Covered140
Insurance policy start date2017-07-01
Insurance policy end date2018-06-30
Total amount of commissions paid to insurance brokerUSD $11,709
Total amount of fees paid to insurance companyUSD $0
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedAD&D AND VOLUNTARY LIFE
Welfare Benefit Premiums Paid to CarrierUSD $78,060
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number21059
Policy instance 1
Insurance contract or identification number21059
Number of Individuals Covered121
Insurance policy start date2015-07-01
Insurance policy end date2016-06-30
Total amount of commissions paid to insurance brokerUSD $9,512
Total amount of fees paid to insurance companyUSD $0
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedAD&D AND VOLUNTARY LIFE
Welfare Benefit Premiums Paid to CarrierUSD $63,414
Commission paid to Insurance BrokerUSD $9,512
Insurance broker organization code?3
Insurance broker nameNORTHWESTERN BENEFIT CORP OF GA
BLUE CROSS AND BLUE SHIELD OF GEORGIA, INC/ (G0385) (National Association of Insurance Commissioners NAIC id number: 54801 )
Policy contract number1006889000
Policy instance 2
Insurance contract or identification number1006889000
Number of Individuals Covered121
Insurance policy start date2015-07-01
Insurance policy end date2016-06-30
Total amount of commissions paid to insurance brokerUSD $45,255
Total amount of fees paid to insurance companyUSD $828
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,303,300
Commission paid to Insurance BrokerUSD $45,255
Amount paid for insurance broker fees828
Additional information about fees paid to insurance brokerBONUS
Insurance broker organization code?3
Insurance broker nameNORTHWESTERN BENEFIT CORP OF GA
BLUE CROSS AND BLUE SHIELD OF GEORGIA, INC/ (G0385) (National Association of Insurance Commissioners NAIC id number: 54801 )
Policy contract number1006889000
Policy instance 1
Insurance contract or identification number1006889000
Number of Individuals Covered115
Insurance policy start date2014-07-01
Insurance policy end date2015-06-30
Total amount of commissions paid to insurance brokerUSD $49,064
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,227,732
Commission paid to Insurance BrokerUSD $49,064
Insurance broker organization code?3
Insurance broker nameNORTHWESTERN BENEFIT CORP OF GA
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number21059
Policy instance 2
Insurance contract or identification number21059
Number of Individuals Covered117
Insurance policy start date2014-07-01
Insurance policy end date2015-06-30
Total amount of commissions paid to insurance brokerUSD $9,066
Total amount of fees paid to insurance companyUSD $0
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedAD&D AND VOLUNTARY LIFE
Welfare Benefit Premiums Paid to CarrierUSD $60,438
Commission paid to Insurance BrokerUSD $9,066
Insurance broker organization code?3
Insurance broker nameNORTHWESTERN BENEFIT CORP OF GA
BLUE CROSS AND BLUE SHIELD OF GEORGIA, INC/ (G0385) (National Association of Insurance Commissioners NAIC id number: 54801 )
Policy contract number1006889000
Policy instance 2
Insurance contract or identification number1006889000
Number of Individuals Covered118
Insurance policy start date2013-07-01
Insurance policy end date2014-06-30
Total amount of commissions paid to insurance brokerUSD $48,683
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,177,231
Commission paid to Insurance BrokerUSD $48,683
Insurance broker organization code?3
Insurance broker nameNORTHWESTERN BENEFIT CORP OF GA
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number21059
Policy instance 1
Insurance contract or identification number21059
Number of Individuals Covered118
Insurance policy start date2013-07-01
Insurance policy end date2014-06-30
Total amount of commissions paid to insurance brokerUSD $7,992
Total amount of fees paid to insurance companyUSD $0
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedAD&D AND VOLUNTARY LIFE
Welfare Benefit Premiums Paid to CarrierUSD $53,278
Commission paid to Insurance BrokerUSD $7,992
Insurance broker organization code?3
Insurance broker nameNORTHWESTERN BENEFIT CORP OF GA
BLUE CROSS AND BLUE SHIELD OF GEORGIA, INC/ (G0385) (National Association of Insurance Commissioners NAIC id number: 54801 )
Policy contract number1006889000
Policy instance 2
Insurance contract or identification number1006889000
Number of Individuals Covered112
Insurance policy start date2012-07-01
Insurance policy end date2013-06-30
Total amount of commissions paid to insurance brokerUSD $31,211
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $937,832
Commission paid to Insurance BrokerUSD $31,211
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameNORTHWESTERN BENEFIT CORP OF GA
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number21059
Policy instance 1
Insurance contract or identification number21059
Number of Individuals Covered112
Insurance policy start date2012-07-01
Insurance policy end date2013-06-30
Total amount of commissions paid to insurance brokerUSD $8,802
Total amount of fees paid to insurance companyUSD $0
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedAD&D AND VOLUNTARY LIFE
Welfare Benefit Premiums Paid to CarrierUSD $58,677
Commission paid to Insurance BrokerUSD $8,802
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameNORTHWESTERN BENEFIT CORP OF GA
BLUE CROSS AND BLUE SHIELD OF GEORGIA, INC/ (G0385) (National Association of Insurance Commissioners NAIC id number: 54801 )
Policy contract number1006889000
Policy instance 1
Insurance contract or identification number1006889000
Number of Individuals Covered112
Insurance policy start date2011-07-01
Insurance policy end date2012-06-30
Total amount of commissions paid to insurance brokerUSD $42,241
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $784,197
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number21059
Policy instance 2
Insurance contract or identification number21059
Number of Individuals Covered111
Insurance policy start date2011-07-01
Insurance policy end date2012-06-30
Total amount of commissions paid to insurance brokerUSD $9,866
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedAD&D AND VOLUNTARY LIFE
Welfare Benefit Premiums Paid to CarrierUSD $54,923
BLUE CROSS BLUE SHIELD OF GEORGIA INC. (G0386) (National Association of Insurance Commissioners NAIC id number: 96962 )
Policy contract number1006889000
Policy instance 1
Insurance contract or identification number1006889000
Number of Individuals Covered170
Insurance policy start date2010-07-01
Insurance policy end date2011-06-30
Total amount of commissions paid to insurance brokerUSD $38,360
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $806,991

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