TWIN LAKES REGIONAL MEDICAL CENTER has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan TWIN LAKES REGIONAL MEDICAL CENTER WELFARE BENEFIT PLAN
401k plan membership statisitcs for TWIN LAKES REGIONAL MEDICAL CENTER WELFARE BENEFIT PLAN
| Measure | Date | Value |
|---|
| 2021: TWIN LAKES REGIONAL MEDICAL CENTER WELFARE BENEFIT PLAN 2021 401k membership |
|---|
| Total participants, beginning-of-year | 2021-01-01 | 213 |
| Total number of active participants reported on line 7a of the Form 5500 | 2021-01-01 | 0 |
| 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 | 0 |
| Number of employers contributing to the scheme | 2021-01-01 | 0 |
| 2020: TWIN LAKES REGIONAL MEDICAL CENTER WELFARE BENEFIT PLAN 2020 401k membership |
|---|
| Total participants, beginning-of-year | 2020-01-01 | 213 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-01-01 | 213 |
| 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 | 213 |
| Number of employers contributing to the scheme | 2020-01-01 | 0 |
| 2019: TWIN LAKES REGIONAL MEDICAL CENTER WELFARE BENEFIT PLAN 2019 401k membership |
|---|
| Total participants, beginning-of-year | 2019-01-01 | 253 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-01-01 | 213 |
| 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 | 213 |
| 2018: TWIN LAKES REGIONAL MEDICAL CENTER WELFARE BENEFIT PLAN 2018 401k membership |
|---|
| Total participants, beginning-of-year | 2018-01-01 | 314 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-01-01 | 250 |
| Number of retired or separated participants receiving benefits | 2018-01-01 | 3 |
| Number of other retired or separated participants entitled to future benefits | 2018-01-01 | 0 |
| Total of all active and inactive participants | 2018-01-01 | 253 |
| 2017: TWIN LAKES REGIONAL MEDICAL CENTER WELFARE BENEFIT PLAN 2017 401k membership |
|---|
| Total participants, beginning-of-year | 2017-01-01 | 314 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-01-01 | 314 |
| Number of retired or separated participants receiving benefits | 2017-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2017-01-01 | 0 |
| Total of all active and inactive participants | 2017-01-01 | 314 |
| 2016: TWIN LAKES REGIONAL MEDICAL CENTER WELFARE BENEFIT PLAN 2016 401k membership |
|---|
| Total participants, beginning-of-year | 2016-01-01 | 337 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-01-01 | 314 |
| Number of retired or separated participants receiving benefits | 2016-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2016-01-01 | 0 |
| Total of all active and inactive participants | 2016-01-01 | 314 |
| 2015: TWIN LAKES REGIONAL MEDICAL CENTER WELFARE BENEFIT PLAN 2015 401k membership |
|---|
| Total participants, beginning-of-year | 2015-01-01 | 340 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-01-01 | 337 |
| Number of retired or separated participants receiving benefits | 2015-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2015-01-01 | 0 |
| Total of all active and inactive participants | 2015-01-01 | 337 |
| 2014: TWIN LAKES REGIONAL MEDICAL CENTER WELFARE BENEFIT PLAN 2014 401k membership |
|---|
| Total participants, beginning-of-year | 2014-01-01 | 265 |
| Total number of active participants reported on line 7a of the Form 5500 | 2014-01-01 | 340 |
| Number of retired or separated participants receiving benefits | 2014-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2014-01-01 | 0 |
| Total of all active and inactive participants | 2014-01-01 | 340 |
| 2013: TWIN LAKES REGIONAL MEDICAL CENTER WELFARE BENEFIT PLAN 2013 401k membership |
|---|
| Total participants, beginning-of-year | 2013-01-01 | 306 |
| Total number of active participants reported on line 7a of the Form 5500 | 2013-01-01 | 265 |
| Number of retired or separated participants receiving benefits | 2013-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2013-01-01 | 0 |
| Total of all active and inactive participants | 2013-01-01 | 265 |
| 2012: TWIN LAKES REGIONAL MEDICAL CENTER WELFARE BENEFIT PLAN 2012 401k membership |
|---|
| Total participants, beginning-of-year | 2012-01-01 | 295 |
| Total number of active participants reported on line 7a of the Form 5500 | 2012-01-01 | 306 |
| Number of retired or separated participants receiving benefits | 2012-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2012-01-01 | 0 |
| Total of all active and inactive participants | 2012-01-01 | 306 |
| 2011: TWIN LAKES REGIONAL MEDICAL CENTER WELFARE BENEFIT PLAN 2011 401k membership |
|---|
| Total participants, beginning-of-year | 2011-01-01 | 100 |
| Total number of active participants reported on line 7a of the Form 5500 | 2011-01-01 | 295 |
| Number of retired or separated participants receiving benefits | 2011-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2011-01-01 | 0 |
| Total of all active and inactive participants | 2011-01-01 | 295 |
| 2010: TWIN LAKES REGIONAL MEDICAL CENTER WELFARE BENEFIT PLAN 2010 401k membership |
|---|
| Total participants, beginning-of-year | 2010-01-01 | 100 |
| Total number of active participants reported on line 7a of the Form 5500 | 2010-01-01 | 100 |
| Number of retired or separated participants receiving benefits | 2010-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2010-01-01 | 0 |
| Total of all active and inactive participants | 2010-01-01 | 100 |
| 2009: TWIN LAKES REGIONAL MEDICAL CENTER WELFARE BENEFIT PLAN 2009 401k membership |
|---|
| Total participants, beginning-of-year | 2009-01-01 | 100 |
| Total number of active participants reported on line 7a of the Form 5500 | 2009-01-01 | 100 |
| Number of retired or separated participants receiving benefits | 2009-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2009-01-01 | 0 |
| Total of all active and inactive participants | 2009-01-01 | 100 |
| 2008: TWIN LAKES REGIONAL MEDICAL CENTER WELFARE BENEFIT PLAN 2008 401k membership |
|---|
| Total participants, beginning-of-year | 2008-01-01 | 100 |
| Total number of active participants reported on line 7a of the Form 5500 | 2008-01-01 | 100 |
| Number of retired or separated participants receiving benefits | 2008-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2008-01-01 | 0 |
| Total of all active and inactive participants | 2008-01-01 | 100 |
| 2007: TWIN LAKES REGIONAL MEDICAL CENTER WELFARE BENEFIT PLAN 2007 401k membership |
|---|
| Total participants, beginning-of-year | 2007-01-01 | 100 |
| Total number of active participants reported on line 7a of the Form 5500 | 2007-01-01 | 100 |
| Number of retired or separated participants receiving benefits | 2007-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2007-01-01 | 0 |
| Total of all active and inactive participants | 2007-01-01 | 100 |
| 2006: TWIN LAKES REGIONAL MEDICAL CENTER WELFARE BENEFIT PLAN 2006 401k membership |
|---|
| Total participants, beginning-of-year | 2006-01-01 | 100 |
| Total number of active participants reported on line 7a of the Form 5500 | 2006-01-01 | 100 |
| Number of retired or separated participants receiving benefits | 2006-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2006-01-01 | 0 |
| Total of all active and inactive participants | 2006-01-01 | 100 |
| 2005: TWIN LAKES REGIONAL MEDICAL CENTER WELFARE BENEFIT PLAN 2005 401k membership |
|---|
| Total participants, beginning-of-year | 2005-01-01 | 136 |
| Total number of active participants reported on line 7a of the Form 5500 | 2005-01-01 | 100 |
| Number of retired or separated participants receiving benefits | 2005-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2005-01-01 | 0 |
| Total of all active and inactive participants | 2005-01-01 | 100 |
| 2004: TWIN LAKES REGIONAL MEDICAL CENTER WELFARE BENEFIT PLAN 2004 401k membership |
|---|
| Total participants, beginning-of-year | 2004-01-01 | 100 |
| Total number of active participants reported on line 7a of the Form 5500 | 2004-01-01 | 136 |
| Number of retired or separated participants receiving benefits | 2004-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2004-01-01 | 0 |
| Total of all active and inactive participants | 2004-01-01 | 136 |
| 2021: TWIN LAKES REGIONAL MEDICAL CENTER WELFARE BENEFIT PLAN 2021 form 5500 responses |
|---|
| 2021-01-01 | Type of plan entity | Single employer plan |
| 2021-01-01 | This submission is the final filing | Yes |
| 2021-01-01 | Plan funding arrangement – Insurance | Yes |
| 2021-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2020: TWIN LAKES REGIONAL MEDICAL CENTER 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: TWIN LAKES REGIONAL MEDICAL CENTER WELFARE BENEFIT PLAN 2019 form 5500 responses |
|---|
| 2019-01-01 | Type of plan entity | Single employer plan |
| 2019-01-01 | Submission has been amended | No |
| 2019-01-01 | This submission is the final filing | No |
| 2019-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2019-01-01 | Plan is a collectively bargained plan | No |
| 2019-01-01 | Plan funding arrangement – Insurance | Yes |
| 2019-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2018: TWIN LAKES REGIONAL MEDICAL CENTER WELFARE BENEFIT PLAN 2018 form 5500 responses |
|---|
| 2018-01-01 | Type of plan entity | Single employer plan |
| 2018-01-01 | Submission has been amended | No |
| 2018-01-01 | This submission is the final filing | No |
| 2018-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2018-01-01 | Plan is a collectively bargained plan | No |
| 2018-01-01 | Plan funding arrangement – Insurance | Yes |
| 2018-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2017: TWIN LAKES REGIONAL MEDICAL CENTER WELFARE BENEFIT PLAN 2017 form 5500 responses |
|---|
| 2017-01-01 | Type of plan entity | Single employer plan |
| 2017-01-01 | Submission has been amended | No |
| 2017-01-01 | This submission is the final filing | No |
| 2017-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2017-01-01 | Plan is a collectively bargained plan | No |
| 2017-01-01 | Plan funding arrangement – Insurance | Yes |
| 2017-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2016: TWIN LAKES REGIONAL MEDICAL CENTER WELFARE BENEFIT PLAN 2016 form 5500 responses |
|---|
| 2016-01-01 | Type of plan entity | Single employer plan |
| 2016-01-01 | Submission has been amended | Yes |
| 2016-01-01 | This submission is the final filing | No |
| 2016-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2016-01-01 | Plan is a collectively bargained plan | No |
| 2016-01-01 | Plan funding arrangement – Insurance | Yes |
| 2016-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2015: TWIN LAKES REGIONAL MEDICAL CENTER WELFARE BENEFIT PLAN 2015 form 5500 responses |
|---|
| 2015-01-01 | Type of plan entity | Single employer plan |
| 2015-01-01 | Submission has been amended | No |
| 2015-01-01 | This submission is the final filing | No |
| 2015-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2015-01-01 | Plan is a collectively bargained plan | No |
| 2015-01-01 | Plan funding arrangement – Insurance | Yes |
| 2015-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2014: TWIN LAKES REGIONAL MEDICAL CENTER WELFARE BENEFIT PLAN 2014 form 5500 responses |
|---|
| 2014-01-01 | Type of plan entity | Single employer plan |
| 2014-01-01 | Submission has been amended | No |
| 2014-01-01 | This submission is the final filing | No |
| 2014-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2014-01-01 | Plan is a collectively bargained plan | No |
| 2014-01-01 | Plan funding arrangement – Insurance | Yes |
| 2014-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2013: TWIN LAKES REGIONAL MEDICAL CENTER WELFARE BENEFIT PLAN 2013 form 5500 responses |
|---|
| 2013-01-01 | Type of plan entity | Single employer plan |
| 2013-01-01 | Submission has been amended | No |
| 2013-01-01 | This submission is the final filing | No |
| 2013-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2013-01-01 | Plan is a collectively bargained plan | No |
| 2013-01-01 | Plan funding arrangement – Insurance | Yes |
| 2013-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2012: TWIN LAKES REGIONAL MEDICAL CENTER WELFARE BENEFIT PLAN 2012 form 5500 responses |
|---|
| 2012-01-01 | Type of plan entity | Single employer plan |
| 2012-01-01 | Submission has been amended | No |
| 2012-01-01 | This submission is the final filing | No |
| 2012-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2012-01-01 | Plan is a collectively bargained plan | No |
| 2012-01-01 | Plan funding arrangement – Insurance | Yes |
| 2012-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2011: TWIN LAKES REGIONAL MEDICAL CENTER WELFARE BENEFIT PLAN 2011 form 5500 responses |
|---|
| 2011-01-01 | Type of plan entity | Single employer plan |
| 2011-01-01 | Submission has been amended | No |
| 2011-01-01 | This submission is the final filing | No |
| 2011-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2011-01-01 | Plan is a collectively bargained plan | No |
| 2011-01-01 | Plan funding arrangement – Insurance | Yes |
| 2011-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2010: TWIN LAKES REGIONAL MEDICAL CENTER WELFARE BENEFIT PLAN 2010 form 5500 responses |
|---|
| 2010-01-01 | Type of plan entity | Single employer plan |
| 2010-01-01 | Submission has been amended | No |
| 2010-01-01 | This submission is the final filing | No |
| 2010-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2010-01-01 | Plan is a collectively bargained plan | No |
| 2010-01-01 | Plan funding arrangement – Insurance | Yes |
| 2010-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2009: TWIN LAKES REGIONAL MEDICAL CENTER WELFARE BENEFIT PLAN 2009 form 5500 responses |
|---|
| 2009-01-01 | Type of plan entity | Single employer plan |
| 2009-01-01 | Submission has been amended | No |
| 2009-01-01 | This submission is the final filing | No |
| 2009-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2009-01-01 | Plan is a collectively bargained plan | No |
| 2009-01-01 | Plan funding arrangement – Insurance | Yes |
| 2009-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2008: TWIN LAKES REGIONAL MEDICAL CENTER WELFARE BENEFIT PLAN 2008 form 5500 responses |
|---|
| 2008-01-01 | Type of plan entity | Single employer plan |
| 2008-01-01 | Submission has been amended | No |
| 2008-01-01 | This submission is the final filing | No |
| 2008-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2008-01-01 | Plan is a collectively bargained plan | No |
| 2008-01-01 | Plan funding arrangement – Insurance | Yes |
| 2008-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2007: TWIN LAKES REGIONAL MEDICAL CENTER WELFARE BENEFIT PLAN 2007 form 5500 responses |
|---|
| 2007-01-01 | Type of plan entity | Single employer plan |
| 2007-01-01 | Submission has been amended | No |
| 2007-01-01 | This submission is the final filing | No |
| 2007-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2007-01-01 | Plan is a collectively bargained plan | No |
| 2007-01-01 | Plan funding arrangement – Insurance | Yes |
| 2007-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2006: TWIN LAKES REGIONAL MEDICAL CENTER WELFARE BENEFIT PLAN 2006 form 5500 responses |
|---|
| 2006-01-01 | Type of plan entity | Single employer plan |
| 2006-01-01 | Submission has been amended | No |
| 2006-01-01 | This submission is the final filing | No |
| 2006-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2006-01-01 | Plan is a collectively bargained plan | No |
| 2006-01-01 | Plan funding arrangement – Insurance | Yes |
| 2006-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2005: TWIN LAKES REGIONAL MEDICAL CENTER WELFARE BENEFIT PLAN 2005 form 5500 responses |
|---|
| 2005-01-01 | Type of plan entity | Single employer plan |
| 2005-01-01 | Submission has been amended | No |
| 2005-01-01 | This submission is the final filing | No |
| 2005-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2005-01-01 | Plan is a collectively bargained plan | No |
| 2005-01-01 | Plan funding arrangement – Insurance | Yes |
| 2005-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2004: TWIN LAKES REGIONAL MEDICAL CENTER WELFARE BENEFIT PLAN 2004 form 5500 responses |
|---|
| 2004-01-01 | Type of plan entity | Single employer plan |
| 2004-01-01 | First time form 5500 has been submitted | Yes |
| 2004-01-01 | Submission has been amended | No |
| 2004-01-01 | This submission is the final filing | No |
| 2004-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2004-01-01 | Plan is a collectively bargained plan | No |
| 2004-01-01 | Plan funding arrangement – Insurance | Yes |
| 2004-01-01 | Plan benefit arrangement – Insurance | Yes |
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | GL155852 |
| Policy instance | 2 |
| Insurance contract or identification number | GL155852 | | Number of Individuals Covered | 238 | | Insurance policy start date | 2020-03-01 | | Insurance policy end date | 2021-02-28 | | Total amount of commissions paid to insurance broker | USD $15,002 | | Total amount of fees paid to insurance company | USD $3,501 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $130,168 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $10,731 | | Amount paid for insurance broker fees | 3184 | | Additional information about fees paid to insurance broker | TOTAL ADMINISTRATIVE AND OTHER FEES | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL OF KENTUCKY (National Association of Insurance Commissioners NAIC id number: 54674 ) |
| Policy contract number | 664920 |
| Policy instance | 1 |
| Insurance contract or identification number | 664920 | | Number of Individuals Covered | 0 | | Insurance policy start date | 2020-07-01 | | Insurance policy end date | 2021-06-30 | | Total amount of commissions paid to insurance broker | USD $1,890 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,890 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | LTD119152 |
| Policy instance | 4 |
| Insurance contract or identification number | LTD119152 | | Number of Individuals Covered | 213 | | Insurance policy start date | 2019-03-01 | | Insurance policy end date | 2020-02-29 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 30800-1243 |
| Policy instance | 1 |
| Insurance contract or identification number | 30800-1243 | | Number of Individuals Covered | 213 | | Insurance policy start date | 2019-07-01 | | Insurance policy end date | 2020-06-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | G165104 |
| Policy instance | 2 |
| Insurance contract or identification number | G165104 | | Number of Individuals Covered | 213 | | Insurance policy start date | 2019-03-01 | | Insurance policy end date | 2020-02-29 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Temporary Disability Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| DELTA DENTAL OF KENTUCKY (National Association of Insurance Commissioners NAIC id number: 54674 ) |
| Policy contract number | 664920 |
| Policy instance | 3 |
| Insurance contract or identification number | 664920 | | Number of Individuals Covered | 213 | | Insurance policy start date | 2019-07-01 | | Insurance policy end date | 2020-06-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | GL155852 |
| Policy instance | 5 |
| Insurance contract or identification number | GL155852 | | Number of Individuals Covered | 213 | | Insurance policy start date | 2019-03-01 | | Insurance policy end date | 2020-02-29 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | VG193309 |
| Policy instance | 6 |
| Insurance contract or identification number | VG193309 | | Number of Individuals Covered | 213 | | Insurance policy start date | 2019-03-01 | | Insurance policy end date | 2020-02-29 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 30800-1243 |
| Policy instance | 1 |
| Insurance contract or identification number | 30800-1243 | | Number of Individuals Covered | 444 | | Insurance policy start date | 2018-07-01 | | Insurance policy end date | 2019-06-30 | | Total amount of commissions paid to insurance broker | USD $5,184 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $34,558 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,456 | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL OF KENTUCKY (National Association of Insurance Commissioners NAIC id number: 54674 ) |
| Policy contract number | 0664920 |
| Policy instance | 3 |
| Insurance contract or identification number | 0664920 | | Number of Individuals Covered | 491 | | Insurance policy start date | 2018-07-01 | | Insurance policy end date | 2019-06-30 | | Total amount of commissions paid to insurance broker | USD $3,538 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,538 | | Insurance broker organization code? | 3 |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | LTD 119152 |
| Policy instance | 4 |
| Insurance contract or identification number | LTD 119152 | | Number of Individuals Covered | 9 | | Insurance policy start date | 2018-03-01 | | Insurance policy end date | 2019-02-28 | | Total amount of commissions paid to insurance broker | USD $493 | | Total amount of fees paid to insurance company | USD $59 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $2,466 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $370 | | Amount paid for insurance broker fees | 59 | | Additional information about fees paid to insurance broker | TOTAL ADMINISTRATIVE AND OTHER FEES | | Insurance broker organization code? | 3 |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | GL 155852 |
| Policy instance | 5 |
| Insurance contract or identification number | GL 155852 | | Number of Individuals Covered | 237 | | Insurance policy start date | 2018-03-01 | | Insurance policy end date | 2019-02-28 | | Total amount of commissions paid to insurance broker | USD $1,379 | | Total amount of fees paid to insurance company | USD $202 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $6,895 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,034 | | Amount paid for insurance broker fees | 202 | | Additional information about fees paid to insurance broker | TOTAL ADMINISTRATIVE AND OTHER FEES | | Insurance broker organization code? | 3 |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | G 165104 |
| Policy instance | 2 |
| Insurance contract or identification number | G 165104 | | Number of Individuals Covered | 237 | | Insurance policy start date | 2018-03-01 | | Insurance policy end date | 2019-02-28 | | Total amount of commissions paid to insurance broker | USD $2,733 | | Total amount of fees paid to insurance company | USD $1,563 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $54,660 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,733 | | Amount paid for insurance broker fees | 1563 | | Additional information about fees paid to insurance broker | TOTAL ADMINISTRATIVE AND OTHER FEES | | Insurance broker organization code? | 3 |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | VG 183309 |
| Policy instance | 6 |
| Insurance contract or identification number | VG 183309 | | Number of Individuals Covered | 30 | | Insurance policy start date | 2018-03-01 | | Insurance policy end date | 2019-02-28 | | Total amount of commissions paid to insurance broker | USD $2,265 | | Total amount of fees paid to insurance company | USD $127 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $9,058 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,812 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 127 | | Additional information about fees paid to insurance broker | TOTAL ADMINISTRATIVE AND OTHER FEES |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 30800-1243 |
| Policy instance | 1 |
| Insurance contract or identification number | 30800-1243 | | Number of Individuals Covered | 476 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $5,032 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $33,548 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,355 | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL OF KENTUCKY (National Association of Insurance Commissioners NAIC id number: 54674 ) |
| Policy contract number | 0664920 |
| Policy instance | 3 |
| Insurance contract or identification number | 0664920 | | Number of Individuals Covered | 490 | | Insurance policy start date | 2017-07-01 | | Insurance policy end date | 2018-06-30 | | Total amount of commissions paid to insurance broker | USD $3,971 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,971 | | Insurance broker organization code? | 3 |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | GL 155852 |
| Policy instance | 5 |
| Insurance contract or identification number | GL 155852 | | Number of Individuals Covered | 250 | | Insurance policy start date | 2017-03-01 | | Insurance policy end date | 2018-02-28 | | Total amount of commissions paid to insurance broker | USD $1,233 | | Total amount of fees paid to insurance company | USD $113 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $6,167 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $925 | | Amount paid for insurance broker fees | 113 | | Additional information about fees paid to insurance broker | TOTAL ADMINISTRATIVE AND OTHER FEES | | Insurance broker organization code? | 3 |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | VG 183309 |
| Policy instance | 6 |
| Insurance contract or identification number | VG 183309 | | Number of Individuals Covered | 40 | | Insurance policy start date | 2017-03-01 | | Insurance policy end date | 2018-02-28 | | Total amount of commissions paid to insurance broker | USD $2,003 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $8,012 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,602 | | Insurance broker organization code? | 3 |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | LTD 119152 |
| Policy instance | 4 |
| Insurance contract or identification number | LTD 119152 | | Number of Individuals Covered | 10 | | Insurance policy start date | 2017-03-01 | | Insurance policy end date | 2018-02-28 | | Total amount of commissions paid to insurance broker | USD $769 | | Total amount of fees paid to insurance company | USD $0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $3,844 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $577 | | Insurance broker organization code? | 3 |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | G 165104 |
| Policy instance | 2 |
| Insurance contract or identification number | G 165104 | | Number of Individuals Covered | 250 | | Insurance policy start date | 2017-03-01 | | Insurance policy end date | 2018-02-28 | | Total amount of commissions paid to insurance broker | USD $2,368 | | Total amount of fees paid to insurance company | USD $909 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $47,369 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,368 | | Amount paid for insurance broker fees | 909 | | Additional information about fees paid to insurance broker | TOTAL ADMINISTRATIVE AND OTHER FEES | | Insurance broker organization code? | 3 |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | GL 145406 |
| Policy instance | 5 |
| Insurance contract or identification number | GL 145406 | | Number of Individuals Covered | 257 | | Insurance policy start date | 2016-03-01 | | Insurance policy end date | 2017-02-28 | | Total amount of commissions paid to insurance broker | USD $511 | | Total amount of fees paid to insurance company | USD $153 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $4,377 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $438 | | Amount paid for insurance broker fees | 153 | | Additional information about fees paid to insurance broker | TOTAL ADMINISTRATIVE AND OTHER FEES | | Insurance broker organization code? | 3 | | Insurance broker name | FORESTER BENEFITS MANAGEMENT LLC |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | LTD 119152 |
| Policy instance | 4 |
| Insurance contract or identification number | LTD 119152 | | Number of Individuals Covered | 37 | | Insurance policy start date | 2016-03-01 | | Insurance policy end date | 2017-02-28 | | Total amount of commissions paid to insurance broker | USD $1,202 | | Total amount of fees paid to insurance company | USD $262 | | Long Term Disability Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,061 | | Amount paid for insurance broker fees | 262 | | Additional information about fees paid to insurance broker | TOTAL ADMINISTRATIVE AND FEES PAID | | Insurance broker organization code? | 3 | | Insurance broker name | FORESTER BENEFITS MANAGEMENT LLC |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | G 160228 |
| Policy instance | 2 |
| Insurance contract or identification number | G 160228 | | Number of Individuals Covered | 314 | | Insurance policy start date | 2016-03-01 | | Insurance policy end date | 2017-02-28 | | Total amount of commissions paid to insurance broker | USD $3,141 | | Total amount of fees paid to insurance company | USD $1,367 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $29,313 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,931 | | Amount paid for insurance broker fees | 1367 | | Additional information about fees paid to insurance broker | TOTAL ADMINISTRATIVE AND OTHER FEES | | Insurance broker organization code? | 3 | | Insurance broker name | FORESTER BENEFITS MANAGEMENT LLC |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | VG 183309 |
| Policy instance | 6 |
| Insurance contract or identification number | VG 183309 | | Number of Individuals Covered | 133 | | Insurance policy start date | 2016-03-01 | | Insurance policy end date | 2017-02-28 | | Total amount of commissions paid to insurance broker | USD $1,152 | | Total amount of fees paid to insurance company | USD $827 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $23,048 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,152 | | Amount paid for insurance broker fees | 827 | | Additional information about fees paid to insurance broker | TOTAL ADMINISTRATIVE AND OTHER FEES | | Insurance broker organization code? | 3 | | Insurance broker name | ONB INSURANCE GROUP INC. |
|
| AVESIS INSURANCE INCORPORATED (National Association of Insurance Commissioners NAIC id number: 11163 ) |
| Policy contract number | 30800-1243 |
| Policy instance | 1 |
| Insurance contract or identification number | 30800-1243 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| DELTA DENTAL OF KENTUCKY (National Association of Insurance Commissioners NAIC id number: 54674 ) |
| Policy contract number | 0664920 |
| Policy instance | 3 |
| Insurance contract or identification number | 0664920 | | Number of Individuals Covered | 537 | | Insurance policy start date | 2016-07-01 | | Insurance policy end date | 2017-06-30 | | Total amount of commissions paid to insurance broker | USD $3,971 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,971 | | Insurance broker organization code? | 3 | | Insurance broker name | KENTUCKY HOSPITAL SERVICE COMPANY |
|
| BALTAS VISION, LLC (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | BV035 |
| Policy instance | 1 |
| Insurance contract or identification number | BV035 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | VG 183309 |
| Policy instance | 7 |
| Insurance contract or identification number | VG 183309 | | Number of Individuals Covered | 127 | | Insurance policy start date | 2014-03-01 | | Insurance policy end date | 2015-02-28 | | Total amount of commissions paid to insurance broker | USD $11,351 | | Total amount of fees paid to insurance company | USD $522 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $34,228 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,973 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 522 | | Additional information about fees paid to insurance broker | TOTAL ADMINISTRATIVE AND OTHER FEES | | Insurance broker name | ONB INSURANCE GROUP INC. |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | GL 145406 |
| Policy instance | 6 |
| Insurance contract or identification number | GL 145406 | | Number of Individuals Covered | 291 | | Insurance policy start date | 2014-03-01 | | Insurance policy end date | 2015-02-28 | | Total amount of commissions paid to insurance broker | USD $754 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $7,544 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $754 | | Insurance broker organization code? | 3 | | Insurance broker name | ONB INSURANCE GROUP INC. |
|
| DELTA DENTAL OF KENTUCKY (National Association of Insurance Commissioners NAIC id number: 54674 ) |
| Policy contract number | 0664920 |
| Policy instance | 4 |
| Insurance contract or identification number | 0664920 | | Number of Individuals Covered | 519 | | Insurance policy start date | 2014-07-01 | | Insurance policy end date | 2015-06-30 | | Total amount of commissions paid to insurance broker | USD $4,031 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,031 | | Insurance broker organization code? | 3 | | Insurance broker name | KENTUCKY HOSPITAL SERVICE COMPANY |
|
| DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 ) |
| Policy contract number | MSA00427 |
| Policy instance | 3 |
| Insurance contract or identification number | MSA00427 | | Number of Individuals Covered | 33 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $1,797 | | Total amount of fees paid to insurance company | USD $898 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $7,566 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,797 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 898 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | | Insurance broker name | ARISON INSURANCE SERVICES, INC. |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | G 160228 |
| Policy instance | 2 |
| Insurance contract or identification number | G 160228 | | Number of Individuals Covered | 337 | | Insurance policy start date | 2014-03-01 | | Insurance policy end date | 2015-02-28 | | Total amount of commissions paid to insurance broker | USD $5,685 | | Total amount of fees paid to insurance company | USD $0 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $56,854 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,685 | | Insurance broker organization code? | 3 | | Insurance broker name | ONB INSURANCE GROUP |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | LTD 119152 |
| Policy instance | 5 |
| Insurance contract or identification number | LTD 119152 | | Number of Individuals Covered | 43 | | Insurance policy start date | 2014-03-01 | | Insurance policy end date | 2015-02-28 | | Total amount of commissions paid to insurance broker | USD $1,746 | | Total amount of fees paid to insurance company | USD $0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $11,643 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,746 | | Insurance broker organization code? | 3 | | Insurance broker name | ONB INSURANCE GROUP INC. |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | G 160228 |
| Policy instance | 2 |
| Insurance contract or identification number | G 160228 | | Number of Individuals Covered | 340 | | Insurance policy start date | 2013-03-01 | | Insurance policy end date | 2014-02-28 | | Total amount of commissions paid to insurance broker | USD $5,811 | | Total amount of fees paid to insurance company | USD $0 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $58,110 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,811 | | Insurance broker organization code? | 3 | | Insurance broker name | ONB INSURANCE GROUP |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | GL 145406 |
| Policy instance | 7 |
| Insurance contract or identification number | GL 145406 | | Number of Individuals Covered | 278 | | Insurance policy start date | 2013-03-01 | | Insurance policy end date | 2014-02-28 | | Total amount of commissions paid to insurance broker | USD $898 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $8,980 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $898 | | Insurance broker organization code? | 3 | | Insurance broker name | ONB INSURANCE GROUP INC. |
|
| BALTAS VISION, LLC (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | BV035 |
| Policy instance | 1 |
| Insurance contract or identification number | BV035 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 ) |
| Policy contract number | MSA00427 |
| Policy instance | 3 |
| Insurance contract or identification number | MSA00427 | | Number of Individuals Covered | 30 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $1,265 | | Total amount of fees paid to insurance company | USD $633 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $6,618 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,265 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 633 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | | Insurance broker name | ARISON INSURANCE SERVICES, INC. |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | OK 964438 |
| Policy instance | 4 |
| Insurance contract or identification number | OK 964438 | | Insurance policy start date | 2013-04-01 | | Insurance policy end date | 2014-03-31 | | Total amount of commissions paid to insurance broker | USD $1,195 | | Total amount of fees paid to insurance company | USD $194 | | Other welfare benefits provided | ACCIDENTAL DEATH | | Welfare Benefit Premiums Paid to Carrier | USD $7,967 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $1,195 | | Amount paid for insurance broker fees | 194 | | Additional information about fees paid to insurance broker | OVERRIDE | | Insurance broker organization code? | 3 | | Insurance broker name | KHA SOLUTIONS GROUP |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | LTD 119152 |
| Policy instance | 6 |
| Insurance contract or identification number | LTD 119152 | | Number of Individuals Covered | 44 | | Insurance policy start date | 2013-03-01 | | Insurance policy end date | 2014-02-28 | | Total amount of commissions paid to insurance broker | USD $1,939 | | Total amount of fees paid to insurance company | USD $0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $12,930 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,939 | | Insurance broker organization code? | 3 | | Insurance broker name | ONB INSURANCE GROUP INC. |
|
| DELTA DENTAL OF KENTUCKY (National Association of Insurance Commissioners NAIC id number: 54674 ) |
| Policy contract number | 0664920 |
| Policy instance | 5 |
| Insurance contract or identification number | 0664920 | | Number of Individuals Covered | 528 | | Insurance policy start date | 2013-07-01 | | Insurance policy end date | 2014-06-30 | | Total amount of commissions paid to insurance broker | USD $3,103 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,103 | | Insurance broker organization code? | 3 | | Insurance broker name | KENTUCKY HOSPITAL SERVICE COMPANY |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | VG 183309 |
| Policy instance | 8 |
| Insurance contract or identification number | VG 183309 | | Number of Individuals Covered | 93 | | Insurance policy start date | 2013-03-01 | | Insurance policy end date | 2014-02-28 | | Total amount of commissions paid to insurance broker | USD $14,730 | | Total amount of fees paid to insurance company | USD $430 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $29,461 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $11,784 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 430 | | Additional information about fees paid to insurance broker | TOTAL ADMINISTRATIVE AND OTHER FEES | | Insurance broker name | ONB INSURANCE GROUP INC. |
|
| DELTA DENTAL OF KENTUCKY (National Association of Insurance Commissioners NAIC id number: 54674 ) |
| Policy contract number | 0664920 |
| Policy instance | 5 |
| Insurance contract or identification number | 0664920 | | Number of Individuals Covered | 501 | | Insurance policy start date | 2012-07-01 | | Insurance policy end date | 2013-06-30 | | Total amount of commissions paid to insurance broker | USD $1,970 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,970 | | Insurance broker organization code? | 3 | | Insurance broker name | KENTUCKY HOSPITAL SERVICE COMPANY |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | OK 964438 |
| Policy instance | 4 |
| Insurance contract or identification number | OK 964438 | | Insurance policy start date | 2012-04-01 | | Insurance policy end date | 2013-03-31 | | Total amount of commissions paid to insurance broker | USD $1,433 | | Total amount of fees paid to insurance company | USD $165 | | Other welfare benefits provided | ACCIDENTAL DEATH | | Welfare Benefit Premiums Paid to Carrier | USD $9,554 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $1,433 | | Amount paid for insurance broker fees | 165 | | Additional information about fees paid to insurance broker | OVERRIDE | | Insurance broker organization code? | 3 | | Insurance broker name | KHA SOLUTIONS GROUP |
|
| DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 ) |
| Policy contract number | MSA00427 |
| Policy instance | 3 |
| Insurance contract or identification number | MSA00427 | | Number of Individuals Covered | 31 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $1,662 | | Total amount of fees paid to insurance company | USD $831 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $7,983 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,662 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 831 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | | Insurance broker name | ARISON INSURANCE SERVICES, INC. |
|
| BALTAS VISION, LLC (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | BV035 |
| Policy instance | 1 |
| Insurance contract or identification number | BV035 | | Number of Individuals Covered | 438 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $6,638 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $28,489 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 3202 | | Additional information about fees paid to insurance broker | COMMISSION | | Insurance broker organization code? | 3 | | Insurance broker name | HEALTHSMART BENEFIT HOLDINGS |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | LTD 119152 |
| Policy instance | 6 |
| Insurance contract or identification number | LTD 119152 | | Number of Individuals Covered | 45 | | Insurance policy start date | 2012-03-01 | | Insurance policy end date | 2013-02-28 | | Total amount of commissions paid to insurance broker | USD $1,944 | | Total amount of fees paid to insurance company | USD $166 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $12,963 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,944 | | Amount paid for insurance broker fees | 166 | | Additional information about fees paid to insurance broker | TOTAL ADMINISTRATIVE AND OTHER FEES | | Insurance broker organization code? | 3 | | Insurance broker name | ONB INSURANCE GROUP INC. |
|
| BALTAS VISION, LLC (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | BV035 |
| Policy instance | 7 |
| Insurance contract or identification number | BV035 | | Number of Individuals Covered | 416 | | Insurance policy start date | 2012-07-01 | | Insurance policy end date | 2013-06-30 | | Total amount of commissions paid to insurance broker | USD $3,763 | | Total amount of fees paid to insurance company | USD $2,072 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $25,111 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,819 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 2072 | | Additional information about fees paid to insurance broker | ADMINISTRATION | | Insurance broker name | EMPLOYEE BENEFITS ADMINISTRATORS |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | G 160228 |
| Policy instance | 2 |
| Insurance contract or identification number | G 160228 | | Insurance policy start date | 2012-03-01 | | Insurance policy end date | 2013-02-28 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Temporary Disability Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | GL 145406 |
| Policy instance | 8 |
| Insurance contract or identification number | GL 145406 | | Number of Individuals Covered | 265 | | Insurance policy start date | 2012-03-01 | | Insurance policy end date | 2013-02-28 | | Total amount of commissions paid to insurance broker | USD $801 | | Total amount of fees paid to insurance company | USD $111 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $8,012 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $801 | | Amount paid for insurance broker fees | 111 | | Additional information about fees paid to insurance broker | TOTAL ADMINISTRATIVE AND OTHER FEES | | Insurance broker organization code? | 3 | | Insurance broker name | ONB INSURANCE GROUP INC. |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | VG 183309 |
| Policy instance | 9 |
| Insurance contract or identification number | VG 183309 | | Number of Individuals Covered | 83 | | Insurance policy start date | 2012-03-01 | | Insurance policy end date | 2013-02-28 | | Total amount of commissions paid to insurance broker | USD $6,199 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $17,317 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,697 | | Insurance broker organization code? | 3 | | Insurance broker name | ONB INSURANCE GROUP INC. |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | GL 145406 |
| Policy instance | 6 |
| Insurance contract or identification number | GL 145406 | | Number of Individuals Covered | 268 | | Insurance policy start date | 2011-03-01 | | Insurance policy end date | 2012-02-29 | | Total amount of commissions paid to insurance broker | USD $805 | | Total amount of fees paid to insurance company | USD $48 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $8,046 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $805 | | Amount paid for insurance broker fees | 48 | | Additional information about fees paid to insurance broker | TOTAL ADMINISTRATIVE AND OTHER FEES | | Insurance broker organization code? | 3 | | Insurance broker name | ONB INSURANCE GROUP INC. |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | VG 183309 |
| Policy instance | 7 |
| Insurance contract or identification number | VG 183309 | | Insurance policy start date | 2011-03-01 | | Insurance policy end date | 2012-02-29 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | LTD 119152 |
| Policy instance | 5 |
| Insurance contract or identification number | LTD 119152 | | Insurance policy start date | 2011-03-01 | | Insurance policy end date | 2012-02-29 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| DELTA DENTAL OF KENTUCKY (National Association of Insurance Commissioners NAIC id number: 54674 ) |
| Policy contract number | 0664920 |
| Policy instance | 4 |
| Insurance contract or identification number | 0664920 | | Number of Individuals Covered | 438 | | Insurance policy start date | 2011-07-01 | | Insurance policy end date | 2012-06-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | OK 964438 |
| Policy instance | 3 |
| Insurance contract or identification number | OK 964438 | | Insurance policy start date | 2011-04-01 | | Insurance policy end date | 2012-03-31 | | Total amount of commissions paid to insurance broker | USD $1,447 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | ACCIDENTAL DEATH | | Welfare Benefit Premiums Paid to Carrier | USD $9,649 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $1,447 | | Insurance broker organization code? | 3 | | Insurance broker name | KHA SOLUTIONS GROUP |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | G 160228 |
| Policy instance | 1 |
| Insurance contract or identification number | G 160228 | | Number of Individuals Covered | 306 | | Insurance policy start date | 2011-03-01 | | Insurance policy end date | 2012-02-29 | | Total amount of commissions paid to insurance broker | USD $5,078 | | Total amount of fees paid to insurance company | USD $231 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $50,776 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,078 | | Amount paid for insurance broker fees | 231 | | Additional information about fees paid to insurance broker | TOTAL ADMINISTRATIVE AND OTHER FEES | | Insurance broker organization code? | 3 | | Insurance broker name | ONB INSURANCE GROUP INC. |
|
| DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 ) |
| Policy contract number | MSA00427 |
| Policy instance | 2 |
| Insurance contract or identification number | MSA00427 | | Number of Individuals Covered | 35 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $1,502 | | Total amount of fees paid to insurance company | USD $751 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $7,509 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,502 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 751 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | | Insurance broker name | ARISON INSURANCE SERVICES, INC. |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | LTD 119152 |
| Policy instance | 7 |
| Insurance contract or identification number | LTD 119152 | | Insurance policy start date | 2010-03-01 | | Insurance policy end date | 2011-02-28 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 ) |
| Policy contract number | MSA00427 |
| Policy instance | 6 |
| Insurance contract or identification number | MSA00427 | | Number of Individuals Covered | 29 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2011-12-31 | | Total amount of commissions paid to insurance broker | USD $1,250 | | Total amount of fees paid to insurance company | USD $625 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $6,261 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,250 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 625 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | | Insurance broker name | ARISON INSURANCE SERVICES, INC. |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | OK 964438 |
| Policy instance | 5 |
| Insurance contract or identification number | OK 964438 | | Insurance policy start date | 2010-04-01 | | Insurance policy end date | 2011-03-31 | | Total amount of commissions paid to insurance broker | USD $1,386 | | Total amount of fees paid to insurance company | USD $137 | | Other welfare benefits provided | MEDICAL INDEMNITY, ACCIDENTAL DEATH | | Welfare Benefit Premiums Paid to Carrier | USD $9,240 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $1,386 | | Amount paid for insurance broker fees | 137 | | Additional information about fees paid to insurance broker | OVERRIDE | | Insurance broker organization code? | 3 | | Insurance broker name | KHA SOLUTIONS GROUP |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | VG 183309 |
| Policy instance | 3 |
| Insurance contract or identification number | VG 183309 | | Insurance policy start date | 2010-03-01 | | Insurance policy end date | 2011-02-28 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| DELTA DENTAL OF KENTUCKY (National Association of Insurance Commissioners NAIC id number: 54674 ) |
| Policy contract number | 0664920 |
| Policy instance | 2 |
| Insurance contract or identification number | 0664920 | | Number of Individuals Covered | 431 | | Insurance policy start date | 2010-07-01 | | Insurance policy end date | 2011-06-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | G 160228 |
| Policy instance | 1 |
| Insurance contract or identification number | G 160228 | | Number of Individuals Covered | 295 | | Insurance policy start date | 2010-03-01 | | Insurance policy end date | 2011-02-28 | | Total amount of commissions paid to insurance broker | USD $4,443 | | Total amount of fees paid to insurance company | USD $1,134 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $44,434 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,443 | | Amount paid for insurance broker fees | 1134 | | Additional information about fees paid to insurance broker | TOTAL ADMINISTRATIVE AND OTHER FEES | | Insurance broker organization code? | 3 | | Insurance broker name | ONB INSURANCE GROUP, INC. |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | GL 145406 |
| Policy instance | 4 |
| Insurance contract or identification number | GL 145406 | | Number of Individuals Covered | 255 | | Insurance policy start date | 2010-03-01 | | Insurance policy end date | 2011-02-28 | | Total amount of commissions paid to insurance broker | USD $921 | | Total amount of fees paid to insurance company | USD $228 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $9,206 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $921 | | Amount paid for insurance broker fees | 228 | | Additional information about fees paid to insurance broker | TOTAL ADMINISTRATIVE AND OTHER FEES | | Insurance broker organization code? | 3 | | Insurance broker name | ONB INSURANCE GROUP INC. |
|
| DELTA DENTAL OF KENTUCKY (National Association of Insurance Commissioners NAIC id number: 54674 ) |
| Policy contract number | 0664920 |
| Policy instance | 1 |
| Insurance contract or identification number | 0664920 | | Number of Individuals Covered | 402 | | Insurance policy start date | 2009-07-01 | | Insurance policy end date | 2010-06-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | G 160228 |
| Policy instance | 4 |
| Insurance contract or identification number | G 160228 | | Insurance policy start date | 2009-03-01 | | Insurance policy end date | 2010-02-28 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Temporary Disability Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | GL 145406 |
| Policy instance | 2 |
| Insurance contract or identification number | GL 145406 | | Insurance policy start date | 2009-03-01 | | Insurance policy end date | 2010-02-28 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 ) |
| Policy contract number | MSA00427 |
| Policy instance | 3 |
| Insurance contract or identification number | MSA00427 | | Number of Individuals Covered | 14 | | Insurance policy start date | 2010-01-01 | | Insurance policy end date | 2010-12-31 | | Total amount of commissions paid to insurance broker | USD $1,070 | | Total amount of fees paid to insurance company | USD $535 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $5,352 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,070 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 535 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | | Insurance broker name | ARISON INSURANCE SERVICES, INC. |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | LTD 119152 |
| Policy instance | 5 |
| Insurance contract or identification number | LTD 119152 | | Insurance policy start date | 2009-03-01 | | Insurance policy end date | 2010-02-28 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| DELTA DENTAL OF KENTUCKY (National Association of Insurance Commissioners NAIC id number: 54674 ) |
| Policy contract number | 0664920 |
| Policy instance | 5 |
| Insurance contract or identification number | 0664920 | | Insurance policy start date | 2008-07-01 | | Insurance policy end date | 2009-06-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | LTD 119152 |
| Policy instance | 1 |
| Insurance contract or identification number | LTD 119152 | | Insurance policy start date | 2008-03-01 | | Insurance policy end date | 2009-02-28 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | GL 145406 |
| Policy instance | 2 |
| Insurance contract or identification number | GL 145406 | | Insurance policy start date | 2008-03-01 | | Insurance policy end date | 2009-02-28 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 ) |
| Policy contract number | MSA00427 |
| Policy instance | 4 |
| Insurance contract or identification number | MSA00427 | | Number of Individuals Covered | 21 | | Insurance policy start date | 2009-01-01 | | Insurance policy end date | 2009-12-31 | | Total amount of commissions paid to insurance broker | USD $1,219 | | Total amount of fees paid to insurance company | USD $609 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $6,093 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,219 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 609 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | | Insurance broker name | ARISON INSURANCE SERVICES, INC. |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | G 160228 |
| Policy instance | 3 |
| Insurance contract or identification number | G 160228 | | Insurance policy start date | 2008-03-01 | | Insurance policy end date | 2009-02-28 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Temporary Disability Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | |
| Policy instance | 3 |
| Insurance policy start date | 2008-01-01 | | Insurance policy end date | 2008-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | 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 AND DISMEMBERMENT | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 ) |
| Policy contract number | MSA00427 |
| Policy instance | 2 |
| Insurance contract or identification number | MSA00427 | | Number of Individuals Covered | 28 | | Insurance policy start date | 2008-01-01 | | Insurance policy end date | 2008-12-31 | | Total amount of commissions paid to insurance broker | USD $1,809 | | Total amount of fees paid to insurance company | USD $904 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $9,042 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,809 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 904 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | | Insurance broker name | ARISON INSURANCE SERVICES, INC. |
|
| DELTA DENTAL OF KENTUCKY (National Association of Insurance Commissioners NAIC id number: 54674 ) |
| Policy contract number | 0664920 |
| Policy instance | 1 |
| Insurance contract or identification number | 0664920 | | Insurance policy start date | 2007-07-01 | | Insurance policy end date | 2008-06-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | |
| Policy instance | 3 |
| Insurance policy start date | 2007-01-01 | | Insurance policy end date | 2007-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | 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 AND DISMEMBERMENT | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| DELTA DENTAL OF KENTUCKY (National Association of Insurance Commissioners NAIC id number: 54674 ) |
| Policy contract number | 0664920 |
| Policy instance | 2 |
| Insurance contract or identification number | 0664920 | | Insurance policy start date | 2006-07-01 | | Insurance policy end date | 2007-06-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 ) |
| Policy contract number | MSA00427 |
| Policy instance | 1 |
| Insurance contract or identification number | MSA00427 | | Number of Individuals Covered | 29 | | Insurance policy start date | 2007-01-01 | | Insurance policy end date | 2007-12-31 | | Total amount of commissions paid to insurance broker | USD $1,919 | | Total amount of fees paid to insurance company | USD $959 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $10,404 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,919 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 959 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | | Insurance broker name | ARISON INSURANCE SERVICES, INC. |
|
| JEFFERSON PILOT FINANCIAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70254 ) |
| Policy contract number | |
| Policy instance | 2 |
| Insurance policy start date | 2006-01-01 | | Insurance policy end date | 2006-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | 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 AND DISMEMBERMENT | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| DELTA DENTAL OF KENTUCKY (National Association of Insurance Commissioners NAIC id number: 54674 ) |
| Policy contract number | 0664920 |
| Policy instance | 3 |
| Insurance contract or identification number | 0664920 | | Insurance policy start date | 2005-07-01 | | Insurance policy end date | 2006-06-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 ) |
| Policy contract number | MSA00427 |
| Policy instance | 1 |
| Insurance contract or identification number | MSA00427 | | Number of Individuals Covered | 34 | | Insurance policy start date | 2006-01-01 | | Insurance policy end date | 2006-12-31 | | Total amount of commissions paid to insurance broker | USD $2,026 | | Total amount of fees paid to insurance company | USD $1,013 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $10,131 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,026 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 1013 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | | Insurance broker name | ARISON INSURANCE SERVICES, INC. |
|
| JEFFERSON PILOT FINANCIAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70254 ) |
| Policy contract number | |
| Policy instance | 1 |
| Insurance policy start date | 2005-01-01 | | Insurance policy end date | 2005-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | 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 AND DISMEMBERMENT | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| DELTA DENTAL OF KENTUCKY (National Association of Insurance Commissioners NAIC id number: 54674 ) |
| Policy contract number | 0664920 |
| Policy instance | 2 |
| Insurance contract or identification number | 0664920 | | Insurance policy start date | 2004-07-01 | | Insurance policy end date | 2005-06-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 ) |
| Policy contract number | MSA00427 |
| Policy instance | 3 |
| Insurance contract or identification number | MSA00427 | | Number of Individuals Covered | 32 | | Insurance policy start date | 2005-01-01 | | Insurance policy end date | 2005-12-31 | | Total amount of commissions paid to insurance broker | USD $2,342 | | Total amount of fees paid to insurance company | USD $1,171 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $4,660 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,342 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 1171 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | | Insurance broker name | ARISON INSURANCE SERVICES, INC. |
|
| JEFFERSON PILOT FINANCIAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70254 ) |
| Policy contract number | |
| Policy instance | 1 |
| Insurance policy start date | 2004-01-01 | | Insurance policy end date | 2004-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | 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 AND DISMEMBERMENT | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| DELTA DENTAL OF KENTUCKY (National Association of Insurance Commissioners NAIC id number: 54674 ) |
| Policy contract number | |
| Policy instance | 2 |
| Insurance policy start date | 2003-07-01 | | Insurance policy end date | 2004-06-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 ) |
| Policy contract number | MSA00427 |
| Policy instance | 3 |
| Insurance contract or identification number | MSA00427 | | Number of Individuals Covered | 136 | | Insurance policy start date | 2004-01-01 | | Insurance policy end date | 2004-12-31 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $39,783 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,957 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 3978 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | | Insurance broker name | ARISON INSURANCE SERVICES, INC. |
|
