401k Plan data: US ASSURE INSURANCE SERVICES OF FL, INC. EMPLOYEE AND WELFARE BENEFIT PLAN plan

US ASSURE INSURANCE SERVICES OF FL, INC. EMPLOYEE AND WELFARE BENEFIT PLAN 401k Plan overview

Plan Name	US ASSURE INSURANCE SERVICES OF FL, INC. EMPLOYEE AND WELFARE BENEFIT PLAN
Plan identification number	501

US ASSURE INSURANCE SERVICES OF FL, INC. EMPLOYEE AND WELFARE BENEFIT PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Life insurance Dental Vision Temporary disability (accident and sickness) Long-term disability cover

401k Sponsoring company profile

US ASSURE INSURANCE SERVICES OF FLORIDA, INC. has sponsored the creation of one or more 401k plans.

Company Name: US ASSURE INSURANCE SERVICES OF FLORIDA, INC.

Employer identification number (EIN): 593716329

NAIC Classification: 524210
NAIC Description: Insurance Agencies and Brokerages

Form 5500 Filing Information

Submission information for form 5500 for 401k plan US ASSURE INSURANCE SERVICES OF FL, INC. EMPLOYEE AND WELFARE BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2021-01-01 SELENA BREEDLOVE 2022-06-15
501 2020-01-01 SELENA BREEDLOVE 2021-07-27
501 2019-01-01 SELENA BREEDLOVE 2020-04-28

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed
501	2021-01-01	SELENA BREEDLOVE	2022-06-15
501	2020-01-01	SELENA BREEDLOVE	2021-07-27
501	2019-01-01	SELENA BREEDLOVE	2020-04-28

Plan Statistics for US ASSURE INSURANCE SERVICES OF FL, INC. EMPLOYEE AND WELFARE BENEFIT PLAN

401k plan membership statisitcs for US ASSURE INSURANCE SERVICES OF FL, INC. EMPLOYEE AND WELFARE BENEFIT PLAN

Measure Date Value
2021: US ASSURE INSURANCE SERVICES OF FL, INC. EMPLOYEE AND WELFARE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year 2021-01-01 106
Total number of active participants reported on line 7a of the Form 5500 2021-01-01 124
Number of retired or separated participants receiving benefits 2021-01-01 0
Number of other retired or separated participants entitled to future benefits 2021-01-01 0
Total of all active and inactive participants 2021-01-01 124
2020: US ASSURE INSURANCE SERVICES OF FL, INC. EMPLOYEE AND WELFARE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year 2020-01-01 76
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 106
Number of retired or separated participants receiving benefits 2020-01-01 0
Number of other retired or separated participants entitled to future benefits 2020-01-01 0
Total of all active and inactive participants 2020-01-01 106
2019: US ASSURE INSURANCE SERVICES OF FL, INC. EMPLOYEE AND WELFARE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year 2019-01-01 81
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 76
Number of retired or separated participants receiving benefits 2019-01-01 0
Number of other retired or separated participants entitled to future benefits 2019-01-01 0
Total of all active and inactive participants 2019-01-01 76

Measure	Date	Value
2021: US ASSURE INSURANCE SERVICES OF FL, INC. EMPLOYEE AND WELFARE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year	2021-01-01	106
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	124
Number of retired or separated participants receiving benefits	2021-01-01	0
Number of other retired or separated participants entitled to future benefits	2021-01-01	0
Total of all active and inactive participants	2021-01-01	124
2020: US ASSURE INSURANCE SERVICES OF FL, INC. EMPLOYEE AND WELFARE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	76
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	106
Number of retired or separated participants receiving benefits	2020-01-01	0
Number of other retired or separated participants entitled to future benefits	2020-01-01	0
Total of all active and inactive participants	2020-01-01	106
2019: US ASSURE INSURANCE SERVICES OF FL, INC. EMPLOYEE AND WELFARE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	81
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	76
Number of retired or separated participants receiving benefits	2019-01-01	0
Number of other retired or separated participants entitled to future benefits	2019-01-01	0
Total of all active and inactive participants	2019-01-01	76

Form 5500 Responses for US ASSURE INSURANCE SERVICES OF FL, INC. EMPLOYEE AND WELFARE BENEFIT PLAN

2021: US ASSURE INSURANCE SERVICES OF FL, INC. EMPLOYEE AND WELFARE BENEFIT PLAN 2021 form 5500 responses
2021-01-01	Type of plan entity	Single employer plan
2021-01-01	Plan funding arrangement – Insurance	Yes
2021-01-01	Plan benefit arrangement – Insurance	Yes
2020: US ASSURE INSURANCE SERVICES OF FL, INC. EMPLOYEE AND WELFARE BENEFIT PLAN 2020 form 5500 responses
2020-01-01	Type of plan entity	Single employer plan
2020-01-01	Plan funding arrangement – Insurance	Yes
2020-01-01	Plan benefit arrangement – Insurance	Yes
2019: US ASSURE INSURANCE SERVICES OF FL, INC. EMPLOYEE AND WELFARE BENEFIT PLAN 2019 form 5500 responses
2019-01-01	Type of plan entity	Single employer plan
2019-01-01	Plan funding arrangement – Insurance	Yes
2019-01-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )

Policy contract number

752084

Policy instance

Insurance contract or identification number	752084
Number of Individuals Covered	91
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $3,326
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $19,341
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,326
Insurance broker organization code?	3

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

067633

Policy instance

Insurance contract or identification number	067633
Number of Individuals Covered	123
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $12,260
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $108,885
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $12,260
Insurance broker organization code?	3

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

069157

Policy instance

Insurance contract or identification number	069157
Number of Individuals Covered	12
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $3,181
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $22,611
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,181
Insurance broker organization code?	3

BLUE CROSS BLUE SHIELD OF FLORIDA (National Association of Insurance Commissioners NAIC id number: 98167 )

Policy contract number

33121

Policy instance

Insurance contract or identification number	33121
Number of Individuals Covered	26
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $26,631
Total amount of fees paid to insurance company	USD $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $26,631
Insurance broker organization code?	3

METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )

Policy contract number

TM05994540

Policy instance

Insurance contract or identification number	TM05994540
Number of Individuals Covered	195
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $11,168
Total amount of fees paid to insurance company	USD $2,000
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $103,248
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,168
Amount paid for insurance broker fees	2000
Insurance broker organization code?	3

BLUE CROSS BLUE SHIELD OF FLORIDA (National Association of Insurance Commissioners NAIC id number: 95089 )

Policy contract number

33121

Policy instance

Insurance contract or identification number	33121
Number of Individuals Covered	98
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $49,821
Total amount of fees paid to insurance company	USD $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $49,821
Insurance broker organization code?	3

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

402674

Policy instance

Insurance contract or identification number	402674
Number of Individuals Covered	63
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $4,523
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	LIFESTYLE ADD
Welfare Benefit Premiums Paid to Carrier	USD $28,717
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,523
Insurance broker organization code?	3

STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )

Policy contract number

752084

Policy instance

Insurance contract or identification number	752084
Number of Individuals Covered	79
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $3,449
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $19,023
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,449
Insurance broker organization code?	3

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

402674

Policy instance

Insurance contract or identification number	402674
Number of Individuals Covered	58
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $3,917
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	LIFESTYLE ADD
Welfare Benefit Premiums Paid to Carrier	USD $24,875
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,917
Insurance broker organization code?	3

BLUE CROSS BLUE SHIELD OF FLORIDA (National Association of Insurance Commissioners NAIC id number: 95089 )

Policy contract number

33121

Policy instance

Insurance contract or identification number	33121
Number of Individuals Covered	81
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $49,860
Total amount of fees paid to insurance company	USD $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $49,860
Insurance broker organization code?	3

METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )

Policy contract number

TM05994540

Policy instance

Insurance contract or identification number	TM05994540
Number of Individuals Covered	253
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $9,485
Total amount of fees paid to insurance company	USD $1,785
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $95,941
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,485
Amount paid for insurance broker fees	1785
Insurance broker organization code?	3

BLUE CROSS BLUE SHIELD OF FLORIDA (National Association of Insurance Commissioners NAIC id number: 98167 )

Policy contract number

33121

Policy instance

Insurance contract or identification number	33121
Number of Individuals Covered	25
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $27,363
Total amount of fees paid to insurance company	USD $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $27,363
Insurance broker organization code?	3

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

069157

Policy instance

Insurance contract or identification number	069157
Number of Individuals Covered	12
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $3,082
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $21,686
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,082
Insurance broker organization code?	3

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

067633

Policy instance

Insurance contract or identification number	067633
Number of Individuals Covered	109
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $11,498
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $102,191
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,498
Insurance broker organization code?	3

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

069157

Policy instance

Insurance contract or identification number	069157
Number of Individuals Covered	11
Insurance policy start date	2018-10-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $3,923
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $27,442
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,923
Insurance broker organization code?	3

BLUE CROSS BLUE SHIELD OF FLORIDA (National Association of Insurance Commissioners NAIC id number: 98167 )

Policy contract number

33121

Policy instance

Insurance contract or identification number	33121
Number of Individuals Covered	21
Insurance policy start date	2018-10-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $26,262
Total amount of fees paid to insurance company	USD $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $26,262
Insurance broker organization code?	3

METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )

Policy contract number

TM05994540

Policy instance

Insurance contract or identification number	TM05994540
Number of Individuals Covered	239
Insurance policy start date	2018-10-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $11,296
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $113,242
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,296
Insurance broker organization code?	3

BLUE CROSS BLUE SHIELD OF FLORIDA (National Association of Insurance Commissioners NAIC id number: 95089 )

Policy contract number

33121

Policy instance

Insurance contract or identification number	33121
Number of Individuals Covered	76
Insurance policy start date	2018-10-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $44,174
Total amount of fees paid to insurance company	USD $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $44,174
Insurance broker organization code?	3

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

402674

Policy instance

Insurance contract or identification number	402674
Number of Individuals Covered	56
Insurance policy start date	2018-10-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $4,372
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	LIFESTYLE ADD
Welfare Benefit Premiums Paid to Carrier	USD $27,760
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,372
Insurance broker organization code?	3

STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )

Policy contract number

752084

Policy instance

Insurance contract or identification number	752084
Number of Individuals Covered	70
Insurance policy start date	2018-10-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $3,480
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $21,873
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,480
Insurance broker organization code?	3

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

067633

Policy instance

Insurance contract or identification number	067633
Number of Individuals Covered	107
Insurance policy start date	2018-10-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $13,589
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $120,717
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $13,589
Insurance broker organization code?	3

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Company Name:	US ASSURE INSURANCE SERVICES OF FLORIDA, INC.
Employer identification number (EIN):	593716329
NAIC Classification:	524210
NAIC Description:	Insurance Agencies and Brokerages