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CLINICAL LABORATORY SERVICES HEALTH AND WELFARE PLAN 401k Plan overview

Plan NameCLINICAL LABORATORY SERVICES HEALTH AND WELFARE PLAN
Plan identification number 501

CLINICAL LABORATORY SERVICES HEALTH AND WELFARE PLAN Benefits

401k Plan TypeWelfare Benefit
Plan Features/Benefits
  • Health (other than dental or vision)
  • Life insurance
  • Dental
  • Vision
  • Temporary disability (accident and sickness)
  • Prepaid legal
  • Long-term disability cover
  • Other welfare benefit cover
  • Unfunded, fully insured, or combination unfunded/insured welfare plan that will not file a Form 5500 for next plan year pursuant to 29 CFR 2520.104-20.
  • Unfunded, fully insured, or combination unfunded/insured welfare plan that stopped filing form 5500s in an earlier plan year pursuant to 29 CFR 2520.104-20.

401k Sponsoring company profile

CLINICAL LABORATORY SERVICES, INC. has sponsored the creation of one or more 401k plans.

Company Name:CLINICAL LABORATORY SERVICES, INC.
Employer identification number (EIN):582328865
NAIC Classification:621510
NAIC Description: Medical and Diagnostic Laboratories

Additional information about CLINICAL LABORATORY SERVICES, INC.

Jurisdiction of Incorporation: Florida Department of State Division of Corporations
Incorporation Date: 1991-10-14
Company Identification Number: S87311
Legal Registered Office Address: 7515 W. OAKLAND PARK BLVD.

LAUDERHILL

33319

More information about CLINICAL LABORATORY SERVICES, INC.

Form 5500 Filing Information

Submission information for form 5500 for 401k plan CLINICAL LABORATORY SERVICES HEALTH AND WELFARE PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5012022-02-01
5012021-02-01
5012020-02-01
5012020-02-01
5012016-02-01RUSSELL WATKINS
5012016-02-01

Plan Statistics for CLINICAL LABORATORY SERVICES HEALTH AND WELFARE PLAN

401k plan membership statisitcs for CLINICAL LABORATORY SERVICES HEALTH AND WELFARE PLAN

Measure Date Value
2022: CLINICAL LABORATORY SERVICES HEALTH AND WELFARE PLAN 2022 401k membership
Total participants, beginning-of-year2022-02-01226
Total number of active participants reported on line 7a of the Form 55002022-02-01185
Number of retired or separated participants receiving benefits2022-02-010
Number of other retired or separated participants entitled to future benefits2022-02-010
Total of all active and inactive participants2022-02-01185
2021: CLINICAL LABORATORY SERVICES HEALTH AND WELFARE PLAN 2021 401k membership
Total participants, beginning-of-year2021-02-01135
Total number of active participants reported on line 7a of the Form 55002021-02-01122
Number of retired or separated participants receiving benefits2021-02-010
Number of other retired or separated participants entitled to future benefits2021-02-010
Total of all active and inactive participants2021-02-01122
2020: CLINICAL LABORATORY SERVICES HEALTH AND WELFARE PLAN 2020 401k membership
Total participants, beginning-of-year2020-02-01100
Total number of active participants reported on line 7a of the Form 55002020-02-01135
Number of retired or separated participants receiving benefits2020-02-010
Number of other retired or separated participants entitled to future benefits2020-02-010
Total of all active and inactive participants2020-02-01135
2016: CLINICAL LABORATORY SERVICES HEALTH AND WELFARE PLAN 2016 401k membership
Total participants, beginning-of-year2016-02-0187
Total number of active participants reported on line 7a of the Form 55002016-02-0183
Number of retired or separated participants receiving benefits2016-02-010
Number of other retired or separated participants entitled to future benefits2016-02-010
Total of all active and inactive participants2016-02-0183

Form 5500 Responses for CLINICAL LABORATORY SERVICES HEALTH AND WELFARE PLAN

2022: CLINICAL LABORATORY SERVICES HEALTH AND WELFARE PLAN 2022 form 5500 responses
2022-02-01Type of plan entitySingle employer plan
2022-02-01Submission has been amendedNo
2022-02-01This submission is the final filingNo
2022-02-01This return/report is a short plan year return/report (less than 12 months)No
2022-02-01Plan is a collectively bargained planNo
2022-02-01Plan funding arrangement – InsuranceYes
2022-02-01Plan benefit arrangement – InsuranceYes
2021: CLINICAL LABORATORY SERVICES HEALTH AND WELFARE PLAN 2021 form 5500 responses
2021-02-01Type of plan entitySingle employer plan
2021-02-01Submission has been amendedNo
2021-02-01This submission is the final filingNo
2021-02-01This return/report is a short plan year return/report (less than 12 months)No
2021-02-01Plan is a collectively bargained planNo
2021-02-01Plan funding arrangement – InsuranceYes
2021-02-01Plan benefit arrangement – InsuranceYes
2020: CLINICAL LABORATORY SERVICES HEALTH AND WELFARE PLAN 2020 form 5500 responses
2020-02-01Type of plan entitySingle employer plan
2020-02-01Submission has been amendedNo
2020-02-01This submission is the final filingNo
2020-02-01This return/report is a short plan year return/report (less than 12 months)No
2020-02-01Plan is a collectively bargained planNo
2020-02-01Plan funding arrangement – InsuranceYes
2020-02-01Plan benefit arrangement – InsuranceYes
2016: CLINICAL LABORATORY SERVICES HEALTH AND WELFARE PLAN 2016 form 5500 responses
2016-02-01Type of plan entitySingle employer plan
2016-02-01First time form 5500 has been submittedYes
2016-02-01Submission has been amendedNo
2016-02-01This submission is the final filingNo
2016-02-01This return/report is a short plan year return/report (less than 12 months)No
2016-02-01Plan is a collectively bargained planNo
2016-02-01Plan funding arrangement – InsuranceYes
2016-02-01Plan benefit arrangement – InsuranceYes

Insurance Providers Used on plan

STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )
Policy contract number169685
Policy instance 3
Insurance contract or identification number169685
Number of Individuals Covered79
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $30,255
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH & DISMEMBERMENT, HOSPITAL INDEMNITY, CRITICAL ILLNESS, ACCIDENT
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 $24,335
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $26,121
Insurance broker organization code?3
SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )
Policy contract number931843
Policy instance 2
Insurance contract or identification number931843
Number of Individuals Covered88
Insurance policy start date2022-02-01
Insurance policy end date2023-01-31
Total amount of commissions paid to insurance brokerUSD $5,423
Total amount of fees paid to insurance companyUSD $3,423
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 BenefitYes
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 $55,045
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,423
Amount paid for insurance broker fees711
Additional information about fees paid to insurance brokerBONUS
Insurance broker organization code?3
HUMANA EMPLOYERS HEALTH PLAN OF GEORGIA, INC. (National Association of Insurance Commissioners NAIC id number: 95519 )
Policy contract number776490
Policy instance 1
Insurance contract or identification number776490
Number of Individuals Covered24
Insurance policy start date2022-02-01
Insurance policy end date2023-01-31
Total amount of commissions paid to insurance brokerUSD $8,670
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $252,155
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $8,670
Insurance broker organization code?3
AMERICAN UNITED LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60895 )
Policy contract numberG 00618714
Policy instance 3
Insurance contract or identification numberG 00618714
Number of Individuals Covered161
Insurance policy start date2021-02-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $12,256
Total amount of fees paid to insurance companyUSD $253
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 & 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 $81,706
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $12,256
Amount paid for insurance broker fees253
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )
Policy contract number931843
Policy instance 2
Insurance contract or identification number931843
Number of Individuals Covered97
Insurance policy start date2021-02-01
Insurance policy end date2022-01-31
Total amount of commissions paid to insurance brokerUSD $5,467
Total amount of fees paid to insurance companyUSD $2,733
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 BenefitYes
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 $53,186
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,467
Insurance broker organization code?3
Amount paid for insurance broker fees2518
Additional information about fees paid to insurance brokerOVERRIDE
HUMANA EMPLOYERS HEALTH PLAN OF GEORGIA, INC. (National Association of Insurance Commissioners NAIC id number: 95519 )
Policy contract number776490
Policy instance 1
Insurance contract or identification number776490
Number of Individuals Covered23
Insurance policy start date2021-02-01
Insurance policy end date2022-01-31
Total amount of commissions paid to insurance brokerUSD $7,601
Total amount of fees paid to insurance companyUSD $221
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $176,215
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $7,601
Insurance broker organization code?3
Amount paid for insurance broker fees221
Additional information about fees paid to insurance brokerBONUS
AMERICAN UNITED LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60895 )
Policy contract numberG 00618714
Policy instance 3
Insurance contract or identification numberG 00618714
Number of Individuals Covered184
Insurance policy start date2020-02-01
Insurance policy end date2021-01-31
Total amount of commissions paid to insurance brokerUSD $13,163
Total amount of fees paid to insurance companyUSD $8,120
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 & 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 $87,755
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $13,163
Amount paid for insurance broker fees8120
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )
Policy contract number931843
Policy instance 2
Insurance contract or identification number931843
Number of Individuals Covered89
Insurance policy start date2020-02-01
Insurance policy end date2021-01-31
Total amount of commissions paid to insurance brokerUSD $6,045
Total amount of fees paid to insurance companyUSD $4,349
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 BenefitYes
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 $61,327
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6,045
Amount paid for insurance broker fees1326
Additional information about fees paid to insurance brokerBONUS
Insurance broker organization code?3
HUMANA EMPLOYERS HEALTH PLAN OF GEORGIA, INC. (National Association of Insurance Commissioners NAIC id number: 95519 )
Policy contract number776490
Policy instance 1
Insurance contract or identification number776490
Number of Individuals Covered18
Insurance policy start date2020-02-01
Insurance policy end date2021-01-31
Total amount of commissions paid to insurance brokerUSD $8,416
Total amount of fees paid to insurance companyUSD $924
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $173,689
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $8,416
Insurance broker organization code?3
Amount paid for insurance broker fees924
Additional information about fees paid to insurance brokerBONUS
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGVTL05231
Policy instance 5
Insurance contract or identification numberGVTL05231
Number of Individuals Covered60
Insurance policy start date2016-02-01
Insurance policy end date2017-01-31
Total amount of commissions paid to insurance brokerUSD $3,657
Total amount of fees paid to insurance companyUSD $588
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 & 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 $24,379
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,657
Amount paid for insurance broker fees588
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGUC05231
Policy instance 4
Insurance contract or identification numberGUC05231
Number of Individuals Covered58
Insurance policy start date2016-02-01
Insurance policy end date2017-01-31
Total amount of commissions paid to insurance brokerUSD $2,562
Total amount of fees paid to insurance companyUSD $352
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 $17,081
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,562
Amount paid for insurance broker fees352
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGUPR05231
Policy instance 3
Insurance contract or identification numberGUPR05231
Number of Individuals Covered58
Insurance policy start date2016-02-01
Insurance policy end date2017-01-31
Total amount of commissions paid to insurance brokerUSD $2,441
Total amount of fees paid to insurance companyUSD $376
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 $16,272
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,441
Amount paid for insurance broker fees376
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number437473
Policy instance 2
Insurance contract or identification number437473
Number of Individuals Covered6
Insurance policy start date2016-01-01
Insurance policy end date2016-12-31
Total amount of commissions paid to insurance brokerUSD $574
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $5,737
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $574
Insurance broker organization code?3
BLUE CROSS BLUE SHIELD OF GEORGIA INC. (G0386) (National Association of Insurance Commissioners NAIC id number: 96962 )
Policy contract numberGA8547
Policy instance 1
Insurance contract or identification numberGA8547
Number of Individuals Covered83
Insurance policy start date2016-02-01
Insurance policy end date2017-01-31
Total amount of commissions paid to insurance brokerUSD $33,152
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $612,051
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $33,152
Insurance broker organization code?3

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