SHELBYVILLE LAUNDRY INC has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan SHELBYVILLE LAUNDRY INC WELFARE BENEFIT PLAN
Measure | Date | Value |
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2022: SHELBYVILLE LAUNDRY INC WELFARE BENEFIT PLAN 2022 401k membership |
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Total participants, beginning-of-year | 2022-01-01 | 818 |
Total number of active participants reported on line 7a of the Form 5500 | 2022-01-01 | 933 |
Number of retired or separated participants receiving benefits | 2022-01-01 | 2 |
Number of other retired or separated participants entitled to future benefits | 2022-01-01 | 0 |
Total of all active and inactive participants | 2022-01-01 | 935 |
2021: SHELBYVILLE LAUNDRY INC WELFARE BENEFIT PLAN 2021 401k membership |
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Total participants, beginning-of-year | 2021-01-01 | 844 |
Total number of active participants reported on line 7a of the Form 5500 | 2021-01-01 | 824 |
Number of retired or separated participants receiving benefits | 2021-01-01 | 2 |
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 | 826 |
2016: SHELBYVILLE LAUNDRY INC WELFARE BENEFIT PLAN 2016 401k membership |
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Total participants, beginning-of-year | 2016-09-01 | 236 |
Total number of active participants reported on line 7a of the Form 5500 | 2016-09-01 | 230 |
Total of all active and inactive participants | 2016-09-01 | 230 |
Total participants | 2016-09-01 | 230 |
2015: SHELBYVILLE LAUNDRY INC WELFARE BENEFIT PLAN 2015 401k membership |
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Total participants, beginning-of-year | 2015-09-01 | 218 |
Total number of active participants reported on line 7a of the Form 5500 | 2015-09-01 | 229 |
Total of all active and inactive participants | 2015-09-01 | 229 |
Total participants | 2015-09-01 | 229 |
2014: SHELBYVILLE LAUNDRY INC WELFARE BENEFIT PLAN 2014 401k membership |
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Total participants, beginning-of-year | 2014-09-01 | 177 |
Total number of active participants reported on line 7a of the Form 5500 | 2014-09-01 | 218 |
Number of other retired or separated participants entitled to future benefits | 2014-09-01 | 0 |
Total of all active and inactive participants | 2014-09-01 | 218 |
Total participants | 2014-09-01 | 218 |
2013: SHELBYVILLE LAUNDRY INC WELFARE BENEFIT PLAN 2013 401k membership |
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Total participants, beginning-of-year | 2013-09-01 | 181 |
Total number of active participants reported on line 7a of the Form 5500 | 2013-09-01 | 175 |
Number of retired or separated participants receiving benefits | 2013-09-01 | 0 |
Number of other retired or separated participants entitled to future benefits | 2013-09-01 | 2 |
Total of all active and inactive participants | 2013-09-01 | 177 |
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits | 2013-09-01 | 0 |
Total participants | 2013-09-01 | 177 |
2012: SHELBYVILLE LAUNDRY INC WELFARE BENEFIT PLAN 2012 401k membership |
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Total participants, beginning-of-year | 2012-09-01 | 206 |
Total number of active participants reported on line 7a of the Form 5500 | 2012-09-01 | 179 |
Number of retired or separated participants receiving benefits | 2012-09-01 | 0 |
Number of other retired or separated participants entitled to future benefits | 2012-09-01 | 2 |
Total of all active and inactive participants | 2012-09-01 | 181 |
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits | 2012-09-01 | 0 |
Total participants | 2012-09-01 | 181 |
Total participants, beginning-of-year | 2012-01-01 | 201 |
Total number of active participants reported on line 7a of the Form 5500 | 2012-01-01 | 183 |
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 | 183 |
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits | 2012-01-01 | 0 |
Total participants | 2012-01-01 | 183 |
2011: SHELBYVILLE LAUNDRY INC WELFARE BENEFIT PLAN 2011 401k membership |
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Total participants, beginning-of-year | 2011-01-01 | 171 |
Total number of active participants reported on line 7a of the Form 5500 | 2011-01-01 | 199 |
Number of retired or separated participants receiving benefits | 2011-01-01 | 2 |
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 | 201 |
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits | 2011-01-01 | 0 |
Total participants | 2011-01-01 | 201 |
2010: SHELBYVILLE LAUNDRY INC WELFARE BENEFIT PLAN 2010 401k membership |
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Total participants, beginning-of-year | 2010-01-01 | 174 |
Total number of active participants reported on line 7a of the Form 5500 | 2010-01-01 | 170 |
Number of retired or separated participants receiving benefits | 2010-01-01 | 1 |
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 | 171 |
Total participants | 2010-01-01 | 171 |
2009: SHELBYVILLE LAUNDRY INC WELFARE BENEFIT PLAN 2009 401k membership |
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Total participants, beginning-of-year | 2009-01-01 | 180 |
Total number of active participants reported on line 7a of the Form 5500 | 2009-01-01 | 172 |
Number of retired or separated participants receiving benefits | 2009-01-01 | 2 |
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 | 174 |
Total participants | 2009-01-01 | 174 |
2022: SHELBYVILLE LAUNDRY INC WELFARE BENEFIT PLAN 2022 form 5500 responses |
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2022-01-01 | Type of plan entity | Single employer plan |
2022-01-01 | Submission has been amended | No |
2022-01-01 | This submission is the final filing | No |
2022-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2022-01-01 | Plan is a collectively bargained plan | No |
2022-01-01 | Plan funding arrangement – Insurance | Yes |
2022-01-01 | Plan benefit arrangement – Insurance | Yes |
2021: SHELBYVILLE LAUNDRY INC WELFARE BENEFIT PLAN 2021 form 5500 responses |
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2021-01-01 | Type of plan entity | Single employer plan |
2021-01-01 | Submission has been amended | No |
2021-01-01 | This submission is the final filing | No |
2021-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2021-01-01 | Plan is a collectively bargained plan | No |
2021-01-01 | Plan funding arrangement – Insurance | Yes |
2021-01-01 | Plan benefit arrangement – Insurance | Yes |
2016: SHELBYVILLE LAUNDRY INC WELFARE BENEFIT PLAN 2016 form 5500 responses |
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2016-09-01 | Type of plan entity | Single employer plan |
2016-09-01 | Submission has been amended | Yes |
2016-09-01 | This submission is the final filing | Yes |
2016-09-01 | Plan funding arrangement – Insurance | Yes |
2016-09-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2016-09-01 | Plan benefit arrangement – Insurance | Yes |
2016-09-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
2015: SHELBYVILLE LAUNDRY INC WELFARE BENEFIT PLAN 2015 form 5500 responses |
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2015-09-01 | Type of plan entity | Single employer plan |
2015-09-01 | Plan funding arrangement – Insurance | Yes |
2015-09-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2015-09-01 | Plan benefit arrangement – Insurance | Yes |
2015-09-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
2014: SHELBYVILLE LAUNDRY INC WELFARE BENEFIT PLAN 2014 form 5500 responses |
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2014-09-01 | Type of plan entity | Single employer plan |
2014-09-01 | Plan funding arrangement – Insurance | Yes |
2014-09-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2014-09-01 | Plan benefit arrangement – Insurance | Yes |
2014-09-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
2013: SHELBYVILLE LAUNDRY INC WELFARE BENEFIT PLAN 2013 form 5500 responses |
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2013-09-01 | Type of plan entity | Single employer plan |
2013-09-01 | Plan funding arrangement – Insurance | Yes |
2013-09-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2013-09-01 | Plan benefit arrangement – Insurance | Yes |
2013-09-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
2012: SHELBYVILLE LAUNDRY INC WELFARE BENEFIT PLAN 2012 form 5500 responses |
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2012-09-01 | Type of plan entity | Single employer plan |
2012-09-01 | Plan funding arrangement – Insurance | Yes |
2012-09-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2012-09-01 | Plan benefit arrangement – Insurance | Yes |
2012-09-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
2012-01-01 | Type of plan entity | Single employer plan |
2012-01-01 | This return/report is a short plan year return/report (less than 12 months) | Yes |
2012-01-01 | Plan funding arrangement – Insurance | Yes |
2012-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2012-01-01 | Plan benefit arrangement – Insurance | Yes |
2012-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
2011: SHELBYVILLE LAUNDRY INC WELFARE BENEFIT PLAN 2011 form 5500 responses |
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2011-01-01 | Type of plan entity | Single employer plan |
2011-01-01 | Plan funding arrangement – Insurance | Yes |
2011-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2011-01-01 | Plan benefit arrangement – Insurance | Yes |
2011-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
2010: SHELBYVILLE LAUNDRY INC WELFARE BENEFIT PLAN 2010 form 5500 responses |
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2010-01-01 | Type of plan entity | Single employer plan |
2010-01-01 | Plan funding arrangement – Insurance | Yes |
2010-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2010-01-01 | Plan benefit arrangement – Insurance | Yes |
2010-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
2009: SHELBYVILLE LAUNDRY INC WELFARE BENEFIT PLAN 2009 form 5500 responses |
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2009-01-01 | Type of plan entity | Single employer plan |
2009-01-01 | Plan funding arrangement – Insurance | Yes |
2009-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2009-01-01 | Plan benefit arrangement – Insurance | Yes |
2009-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
Policy contract number | 00024570 |
Policy instance | 5 |
Insurance contract or identification number | 00024570 | Number of Individuals Covered | 898 | Insurance policy start date | 2022-01-01 | Insurance policy end date | 2022-12-30 | Total amount of commissions paid to insurance broker | USD $60,129 | Total amount of fees paid to insurance company | USD $5,465 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare 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 | VOLUNTARY ACCIDENT, AD&D, OPTIONAL AD&D, VOL CRITICAL ILLNESS, OPTIONAL LIFE | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $177,573 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $32,073 | Insurance broker organization code? | 3 | Amount paid for insurance broker fees | 5465 | Additional information about fees paid to insurance broker | FEES |
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WYSSTA INSURANCE COMPANY INC. (National Association of Insurance Commissioners NAIC id number: 12352 ) |
Policy contract number | 41071 |
Policy instance | 4 |
Insurance contract or identification number | 41071 | Number of Individuals Covered | 349 | Insurance policy start date | 2022-01-01 | Insurance policy end date | 2022-08-31 | Total amount of commissions paid to insurance broker | USD $2,036 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | Yes | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $25,633 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $1,331 | Insurance broker organization code? | 3 |
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DELTA DENTAL OF WISCONSIN (National Association of Insurance Commissioners NAIC id number: 54046 ) |
Policy contract number | 54715 |
Policy instance | 3 |
Insurance contract or identification number | 54715 | Number of Individuals Covered | 426 | Insurance policy start date | 2022-01-01 | Insurance policy end date | 2022-08-31 | Total amount of commissions paid to insurance broker | USD $7,709 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | Yes | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $0 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $4,980 | Insurance broker organization code? | 3 |
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BLUE CROSS BLUE SHIELD OF WISCONSIN (National Association of Insurance Commissioners NAIC id number: 54003 ) |
Policy contract number | L03552 |
Policy instance | 2 |
Insurance contract or identification number | L03552 | Number of Individuals Covered | 491 | Insurance policy start date | 2022-01-01 | Insurance policy end date | 2022-08-31 | Total amount of commissions paid to insurance broker | USD $123,162 | Total amount of fees paid to insurance company | USD $5,000 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | Yes | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $3,054,235 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $102,555 | Amount paid for insurance broker fees | 5000 | Additional information about fees paid to insurance broker | FEES | Insurance broker organization code? | 3 |
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UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
Policy contract number | 0928487 |
Policy instance | 1 |
Insurance contract or identification number | 0928487 | Number of Individuals Covered | 1223 | Insurance policy start date | 2022-09-01 | Insurance policy end date | 2022-12-31 | Total amount of commissions paid to insurance broker | USD $2,515 | Total amount of fees paid to insurance company | USD $37,486 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | Yes | Dental Insurance Welfare Benefit | Yes | Vision Insurance Welfare Benefit | Yes | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $1,698,686 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $2,515 | Amount paid for insurance broker fees | 37486 | Additional information about fees paid to insurance broker | FEES | Insurance broker organization code? | 3 |
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MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
Policy contract number | GLTD0BF4N |
Policy instance | 12 |
Insurance contract or identification number | GLTD0BF4N | Number of Individuals Covered | 42 | Insurance policy start date | 2021-01-01 | Insurance policy end date | 2021-09-01 | Total amount of commissions paid to insurance broker | USD $2,499 | Total amount of fees paid to insurance company | USD $2,608 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | Yes | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $16,659 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $2,499 | Amount paid for insurance broker fees | 1442 | Additional information about fees paid to insurance broker | FEES | Insurance broker organization code? | 3 |
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THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
Policy contract number | 00024570 |
Policy instance | 11 |
Insurance contract or identification number | 00024570 | Number of Individuals Covered | 802 | Insurance policy start date | 2021-09-01 | Insurance policy end date | 2021-12-31 | Total amount of commissions paid to insurance broker | USD $9,223 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare 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 | ACCIDENT, AD&D, OPTIONAL AD&D, VOL CRITICAL ILLNESS | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $58,190 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $9,223 | Insurance broker organization code? | 3 |
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MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
Policy contract number | GVTL0BF4N |
Policy instance | 10 |
Insurance contract or identification number | GVTL0BF4N | Number of Individuals Covered | 107 | Insurance policy start date | 2021-01-01 | Insurance policy end date | 2021-09-01 | Total amount of commissions paid to insurance broker | USD $5,324 | Total amount of fees paid to insurance company | USD $3,501 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | VOL LIFE, VOL AD&D | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $35,495 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $5,324 | Amount paid for insurance broker fees | 3501 | Additional information about fees paid to insurance broker | FEES | Insurance broker organization code? | 3 |
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MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
Policy contract number | GLUG0BF4N |
Policy instance | 9 |
Insurance contract or identification number | GLUG0BF4N | Number of Individuals Covered | 768 | Insurance policy start date | 2021-01-01 | Insurance policy end date | 2021-09-01 | Total amount of commissions paid to insurance broker | USD $2,755 | Total amount of fees paid to insurance company | USD $3,704 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | AD&D | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $18,368 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $2,755 | Amount paid for insurance broker fees | 2418 | Additional information about fees paid to insurance broker | FEES | Insurance broker organization code? | 3 |
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HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
Policy contract number | 888790G |
Policy instance | 8 |
Insurance contract or identification number | 888790G | Number of Individuals Covered | 90 | Insurance policy start date | 2021-01-01 | Insurance policy end date | 2021-08-31 | Total amount of commissions paid to insurance broker | USD $7,124 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | Yes | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | VOL ACCIDENT, VOL CI | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $49,831 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $7,124 | Insurance broker organization code? | 3 |
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WYSSTA INSURANCE COMPANY INC. (National Association of Insurance Commissioners NAIC id number: 12352 ) |
Policy contract number | 41071 |
Policy instance | 7 |
Insurance contract or identification number | 41071 | Number of Individuals Covered | 338 | Insurance policy start date | 2021-09-01 | Insurance policy end date | 2021-12-31 | Total amount of commissions paid to insurance broker | USD $999 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | Yes | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $12,420 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $999 | Insurance broker organization code? | 3 |
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WYSSTA INSURANCE COMPANY INC. (National Association of Insurance Commissioners NAIC id number: 12352 ) |
Policy contract number | 41071 |
Policy instance | 6 |
Insurance contract or identification number | 41071 | Number of Individuals Covered | 326 | Insurance policy start date | 2021-01-01 | Insurance policy end date | 2021-08-31 | Total amount of commissions paid to insurance broker | USD $1,970 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | Yes | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $26,185 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $1,213 | Insurance broker organization code? | 3 |
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DELTA DENTAL OF WISCONSIN (National Association of Insurance Commissioners NAIC id number: 54046 ) |
Policy contract number | 54715 |
Policy instance | 5 |
Insurance contract or identification number | 54715 | Number of Individuals Covered | 414 | Insurance policy start date | 2021-09-01 | Insurance policy end date | 2021-12-31 | Total amount of commissions paid to insurance broker | USD $3,813 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | Yes | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $0 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $3,813 | Insurance broker organization code? | 3 |
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DELTA DENTAL OF WISCONSIN (National Association of Insurance Commissioners NAIC id number: 54046 ) |
Policy contract number | 54715 |
Policy instance | 4 |
Insurance contract or identification number | 54715 | Number of Individuals Covered | 391 | Insurance policy start date | 2021-01-01 | Insurance policy end date | 2021-08-31 | Total amount of commissions paid to insurance broker | USD $7,645 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | Yes | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $0 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $4,817 | Insurance broker organization code? | 3 |
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COMPCARE HEALTH SERVICES INSURANCE CORPORATION (National Association of Insurance Commissioners NAIC id number: 95693 ) |
Policy contract number | L03552 |
Policy instance | 3 |
Insurance contract or identification number | L03552 | Number of Individuals Covered | 80 | Insurance policy start date | 2021-09-01 | Insurance policy end date | 2021-12-31 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | Yes | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $120,944 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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BLUE CROSS BLUE SHIELD OF WISCONSIN (National Association of Insurance Commissioners NAIC id number: 54003 ) |
Policy contract number | L03552 |
Policy instance | 2 |
Insurance contract or identification number | L03552 | Number of Individuals Covered | 492 | Insurance policy start date | 2021-09-01 | Insurance policy end date | 2021-12-31 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | Yes | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $657,461 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
Policy contract number | 0905405 |
Policy instance | 1 |
Insurance contract or identification number | 0905405 | Number of Individuals Covered | 399 | Insurance policy start date | 2021-01-01 | Insurance policy end date | 2021-08-31 | Total amount of commissions paid to insurance broker | USD $2 | Total amount of fees paid to insurance company | USD $83,323 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | Yes | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $2,618,085 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Amount paid for insurance broker fees | 67617 | Additional information about fees paid to insurance broker | SERVICE FEE AGREEMENT | Insurance broker organization code? | 3 | Commission paid to Insurance Broker | USD $2 |
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