THE LILLY COMPANY has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan THE LILLY COMPANY FLEXIBLE BENEFITS PLAN
| Measure | Date | Value |
|---|
| 2022: THE LILLY COMPANY FLEXIBLE BENEFITS PLAN 2022 401k membership |
|---|
| Total participants, beginning-of-year | 2022-05-01 | 230 |
| Total number of active participants reported on line 7a of the Form 5500 | 2022-05-01 | 302 |
| Total of all active and inactive participants | 2022-05-01 | 302 |
| 2021: THE LILLY COMPANY FLEXIBLE BENEFITS PLAN 2021 401k membership |
|---|
| Total participants, beginning-of-year | 2021-05-01 | 202 |
| Total number of active participants reported on line 7a of the Form 5500 | 2021-05-01 | 230 |
| Total of all active and inactive participants | 2021-05-01 | 230 |
| 2020: THE LILLY COMPANY FLEXIBLE BENEFITS PLAN 2020 401k membership |
|---|
| Total participants, beginning-of-year | 2020-05-01 | 183 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-05-01 | 202 |
| Total of all active and inactive participants | 2020-05-01 | 202 |
| 2019: THE LILLY COMPANY FLEXIBLE BENEFITS PLAN 2019 401k membership |
|---|
| Total participants, beginning-of-year | 2019-05-01 | 219 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-05-01 | 183 |
| Total of all active and inactive participants | 2019-05-01 | 183 |
| 2018: THE LILLY COMPANY FLEXIBLE BENEFITS PLAN 2018 401k membership |
|---|
| Total participants, beginning-of-year | 2018-05-01 | 217 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-05-01 | 219 |
| Total of all active and inactive participants | 2018-05-01 | 219 |
| 2017: THE LILLY COMPANY FLEXIBLE BENEFITS PLAN 2017 401k membership |
|---|
| Total participants, beginning-of-year | 2017-05-01 | 209 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-05-01 | 217 |
| Total of all active and inactive participants | 2017-05-01 | 217 |
| 2016: THE LILLY COMPANY FLEXIBLE BENEFITS PLAN 2016 401k membership |
|---|
| Total participants, beginning-of-year | 2016-05-01 | 251 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-05-01 | 209 |
| Total of all active and inactive participants | 2016-05-01 | 209 |
| 2015: THE LILLY COMPANY FLEXIBLE BENEFITS PLAN 2015 401k membership |
|---|
| Total participants, beginning-of-year | 2015-05-01 | 235 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-05-01 | 251 |
| Total of all active and inactive participants | 2015-05-01 | 251 |
| 2014: THE LILLY COMPANY FLEXIBLE BENEFITS PLAN 2014 401k membership |
|---|
| Total participants, beginning-of-year | 2014-05-01 | 179 |
| Total number of active participants reported on line 7a of the Form 5500 | 2014-05-01 | 235 |
| Total of all active and inactive participants | 2014-05-01 | 235 |
| 2013: THE LILLY COMPANY FLEXIBLE BENEFITS PLAN 2013 401k membership |
|---|
| Total participants, beginning-of-year | 2013-05-01 | 170 |
| Total number of active participants reported on line 7a of the Form 5500 | 2013-05-01 | 179 |
| Total of all active and inactive participants | 2013-05-01 | 179 |
| 2012: THE LILLY COMPANY FLEXIBLE BENEFITS PLAN 2012 401k membership |
|---|
| Total participants, beginning-of-year | 2012-05-01 | 152 |
| Total number of active participants reported on line 7a of the Form 5500 | 2012-05-01 | 170 |
| Total of all active and inactive participants | 2012-05-01 | 170 |
| 2011: THE LILLY COMPANY FLEXIBLE BENEFITS PLAN 2011 401k membership |
|---|
| Total participants, beginning-of-year | 2011-05-01 | 151 |
| Total number of active participants reported on line 7a of the Form 5500 | 2011-05-01 | 152 |
| Total of all active and inactive participants | 2011-05-01 | 152 |
| 2010: THE LILLY COMPANY FLEXIBLE BENEFITS PLAN 2010 401k membership |
|---|
| Total participants, beginning-of-year | 2010-05-01 | 125 |
| Total number of active participants reported on line 7a of the Form 5500 | 2010-05-01 | 151 |
| Total of all active and inactive participants | 2010-05-01 | 151 |
| 2009: THE LILLY COMPANY FLEXIBLE BENEFITS PLAN 2009 401k membership |
|---|
| Total participants, beginning-of-year | 2009-05-01 | 211 |
| Total number of active participants reported on line 7a of the Form 5500 | 2009-05-01 | 125 |
| Total of all active and inactive participants | 2009-05-01 | 125 |
| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
| Policy contract number | 00629931 |
| Policy instance | 6 |
| Insurance contract or identification number | 00629931 | | Number of Individuals Covered | 349 | | Insurance policy start date | 2022-05-01 | | Insurance policy end date | 2023-04-30 | | Total amount of commissions paid to insurance broker | USD $2,365 | | Total amount of fees paid to insurance company | USD $72,419 | | Health Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $2,330,868 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,365 | | Amount paid for insurance broker fees | 72419 | | Additional information about fees paid to insurance broker | BENEFIT ADVISOR FEE | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | SGD600709 |
| Policy instance | 5 |
| Insurance contract or identification number | SGD600709 | | Number of Individuals Covered | 295 | | Insurance policy start date | 2021-10-01 | | Insurance policy end date | 2022-09-30 | | Total amount of commissions paid to insurance broker | USD $5,084 | | Total amount of fees paid to insurance company | USD $0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $37,154 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,821 | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | SOK600385 |
| Policy instance | 4 |
| Insurance contract or identification number | SOK600385 | | Number of Individuals Covered | 295 | | Insurance policy start date | 2021-10-01 | | Insurance policy end date | 2022-09-30 | | Total amount of commissions paid to insurance broker | USD $449 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $3,271 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $247 | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | SGM600844 |
| Policy instance | 3 |
| Insurance contract or identification number | SGM600844 | | Number of Individuals Covered | 295 | | Insurance policy start date | 2021-10-01 | | Insurance policy end date | 2022-09-30 | | Total amount of commissions paid to insurance broker | USD $3,927 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $28,631 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,147 | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL OF TENNESSEE (National Association of Insurance Commissioners NAIC id number: 54526 ) |
| Policy contract number | 1648 |
| Policy instance | 2 |
| Insurance contract or identification number | 1648 | | Number of Individuals Covered | 573 | | Insurance policy start date | 2022-05-01 | | Insurance policy end date | 2023-04-30 | | Total amount of commissions paid to insurance broker | USD $13,767 | | 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 $13,767 | | Insurance broker organization code? | 3 |
|
| COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 ) |
| Policy contract number | E9883430 |
| Policy instance | 1 |
| Insurance contract or identification number | E9883430 | | Number of Individuals Covered | 154 | | Insurance policy start date | 2022-05-01 | | Insurance policy end date | 2023-04-30 | | Total amount of commissions paid to insurance broker | USD $27,415 | | Total amount of fees paid to insurance company | USD $4,268 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $193,304 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $24,005 | | Amount paid for insurance broker fees | 2488 | | Additional information about fees paid to insurance broker | BROKER BONUS | | Insurance broker organization code? | 3 |
|
| COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 ) |
| Policy contract number | E9883430 |
| Policy instance | 1 |
| Insurance contract or identification number | E9883430 | | Number of Individuals Covered | 144 | | Insurance policy start date | 2021-05-01 | | Insurance policy end date | 2022-04-30 | | Total amount of commissions paid to insurance broker | USD $19,465 | | Total amount of fees paid to insurance company | USD $3,949 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $149,397 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $16,984 | | Amount paid for insurance broker fees | 2930 | | Additional information about fees paid to insurance broker | BROKER BONUS | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL OF TENNESSEE (National Association of Insurance Commissioners NAIC id number: 54526 ) |
| Policy contract number | 1648 |
| Policy instance | 2 |
| Insurance contract or identification number | 1648 | | Number of Individuals Covered | 554 | | Insurance policy start date | 2021-05-01 | | Insurance policy end date | 2022-04-30 | | Total amount of commissions paid to insurance broker | USD $13,140 | | 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 $13,140 | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | SGM600844 |
| Policy instance | 3 |
| Insurance contract or identification number | SGM600844 | | Number of Individuals Covered | 267 | | Insurance policy start date | 2020-10-01 | | Insurance policy end date | 2021-09-30 | | Total amount of commissions paid to insurance broker | USD $4,530 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $30,197 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,530 | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | SOK600385 |
| Policy instance | 4 |
| Insurance contract or identification number | SOK600385 | | Number of Individuals Covered | 267 | | Insurance policy start date | 2020-10-01 | | Insurance policy end date | 2021-09-30 | | Total amount of commissions paid to insurance broker | USD $509 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $3,398 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $509 | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | SGD600709 |
| Policy instance | 5 |
| Insurance contract or identification number | SGD600709 | | Number of Individuals Covered | 267 | | Insurance policy start date | 2020-10-01 | | Insurance policy end date | 2021-09-30 | | Total amount of commissions paid to insurance broker | USD $5,249 | | Total amount of fees paid to insurance company | USD $0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $34,996 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,249 | | Insurance broker organization code? | 3 |
|
| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
| Policy contract number | 00629931 |
| Policy instance | 6 |
| Insurance contract or identification number | 00629931 | | Number of Individuals Covered | 314 | | Insurance policy start date | 2021-05-01 | | Insurance policy end date | 2022-04-30 | | Total amount of commissions paid to insurance broker | USD $2,141 | | Total amount of fees paid to insurance company | USD $74,866 | | Health Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,893,137 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,141 | | Amount paid for insurance broker fees | 74866 | | Additional information about fees paid to insurance broker | BENEFIT ADVISOR FEE | | Insurance broker organization code? | 3 |
|
| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
| Policy contract number | 00629931 |
| Policy instance | 7 |
| Insurance contract or identification number | 00629931 | | Number of Individuals Covered | 322 | | Insurance policy start date | 2020-05-01 | | Insurance policy end date | 2021-04-30 | | Total amount of commissions paid to insurance broker | USD $1,652 | | Total amount of fees paid to insurance company | USD $61,666 | | Health Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,558,100 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,652 | | Amount paid for insurance broker fees | 61666 | | Additional information about fees paid to insurance broker | BENEFIT ADVISOR FEE | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | SGD600709 |
| Policy instance | 6 |
| Insurance contract or identification number | SGD600709 | | Number of Individuals Covered | 270 | | Insurance policy start date | 2019-10-01 | | Insurance policy end date | 2020-09-30 | | Total amount of commissions paid to insurance broker | USD $5,538 | | Total amount of fees paid to insurance company | USD $0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $36,919 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,538 | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | SOK600385 |
| Policy instance | 5 |
| Insurance contract or identification number | SOK600385 | | Number of Individuals Covered | 270 | | Insurance policy start date | 2019-10-01 | | Insurance policy end date | 2020-09-30 | | Total amount of commissions paid to insurance broker | USD $560 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $3,734 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $560 | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | SGM600844 |
| Policy instance | 4 |
| Insurance contract or identification number | SGM600844 | | Number of Individuals Covered | 270 | | Insurance policy start date | 2019-10-01 | | Insurance policy end date | 2020-09-30 | | Total amount of commissions paid to insurance broker | USD $4,463 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $29,754 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,463 | | Insurance broker organization code? | 3 |
|
| BLUECROSS BLUESHIELD OF TENNESSEE, INC. (National Association of Insurance Commissioners NAIC id number: 54518 ) |
| Policy contract number | 138329 |
| Policy instance | 3 |
| Insurance contract or identification number | 138329 | | Number of Individuals Covered | 451 | | Insurance policy start date | 2019-07-01 | | Insurance policy end date | 2020-06-30 | | Total amount of commissions paid to insurance broker | USD $72,552 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $24,228 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $72,552 | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL OF TENNESSEE (National Association of Insurance Commissioners NAIC id number: 54526 ) |
| Policy contract number | 1648 |
| Policy instance | 2 |
| Insurance contract or identification number | 1648 | | Number of Individuals Covered | 540 | | Insurance policy start date | 2020-05-01 | | Insurance policy end date | 2021-04-30 | | Total amount of commissions paid to insurance broker | USD $12,465 | | 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 $12,465 | | Insurance broker organization code? | 3 |
|
| COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 ) |
| Policy contract number | E9883430 |
| Policy instance | 1 |
| Insurance contract or identification number | E9883430 | | Number of Individuals Covered | 144 | | Insurance policy start date | 2020-05-01 | | Insurance policy end date | 2021-04-30 | | Total amount of commissions paid to insurance broker | USD $21,357 | | Total amount of fees paid to insurance company | USD $3,359 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $157,441 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $18,523 | | Amount paid for insurance broker fees | 2990 | | Additional information about fees paid to insurance broker | BROKER BONUS | | Insurance broker organization code? | 3 |
|
| BLUECROSS BLUESHIELD OF TENNESSEE, INC. (National Association of Insurance Commissioners NAIC id number: 54518 ) |
| Policy contract number | 138329 |
| Policy instance | 6 |
| Insurance contract or identification number | 138329 | | Number of Individuals Covered | 475 | | Insurance policy start date | 2018-07-01 | | Insurance policy end date | 2019-06-30 | | Total amount of commissions paid to insurance broker | USD $71,552 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $26,057 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $71,552 | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | SGD600709 |
| Policy instance | 5 |
| Insurance contract or identification number | SGD600709 | | Number of Individuals Covered | 275 | | Insurance policy start date | 2018-10-01 | | Insurance policy end date | 2019-09-30 | | Total amount of commissions paid to insurance broker | USD $5,784 | | Total amount of fees paid to insurance company | USD $0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $38,562 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,784 | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | SOK600385 |
| Policy instance | 4 |
| Insurance contract or identification number | SOK600385 | | Number of Individuals Covered | 308 | | Insurance policy start date | 2018-10-01 | | Insurance policy end date | 2019-09-30 | | Total amount of commissions paid to insurance broker | USD $604 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $4,027 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $604 | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | SGM600844 |
| Policy instance | 3 |
| Insurance contract or identification number | SGM600844 | | Number of Individuals Covered | 339 | | Insurance policy start date | 2018-10-01 | | Insurance policy end date | 2019-09-30 | | Total amount of commissions paid to insurance broker | USD $4,965 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $33,102 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,965 | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL OF TENNESSEE (National Association of Insurance Commissioners NAIC id number: 54526 ) |
| Policy contract number | 1648 |
| Policy instance | 2 |
| Insurance contract or identification number | 1648 | | Number of Individuals Covered | 552 | | Insurance policy start date | 2019-05-01 | | Insurance policy end date | 2020-04-30 | | Total amount of commissions paid to insurance broker | USD $13,754 | | 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 $13,754 | | Insurance broker organization code? | 3 |
|
| COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 ) |
| Policy contract number | E9883430 |
| Policy instance | 1 |
| Insurance contract or identification number | E9883430 | | Number of Individuals Covered | 144 | | Insurance policy start date | 2019-05-01 | | Insurance policy end date | 2020-04-30 | | Total amount of commissions paid to insurance broker | USD $22,210 | | Total amount of fees paid to insurance company | USD $2,723 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $153,314 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $19,230 | | Amount paid for insurance broker fees | 2115 | | Additional information about fees paid to insurance broker | BROKER BONUS | | Insurance broker organization code? | 3 |
|
| COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 ) |
| Policy contract number | E9883430 |
| Policy instance | 1 |
| Insurance contract or identification number | E9883430 | | Number of Individuals Covered | 140 | | Insurance policy start date | 2018-05-01 | | Insurance policy end date | 2019-04-30 | | Total amount of commissions paid to insurance broker | USD $23,298 | | Total amount of fees paid to insurance company | USD $4,589 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $144,640 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $19,551 | | Amount paid for insurance broker fees | 3393 | | Additional information about fees paid to insurance broker | BROKER BONUS | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL OF TENNESSEE (National Association of Insurance Commissioners NAIC id number: 54526 ) |
| Policy contract number | 1648 |
| Policy instance | 2 |
| Insurance contract or identification number | 1648 | | Number of Individuals Covered | 549 | | Insurance policy start date | 2018-05-01 | | Insurance policy end date | 2019-04-30 | | Total amount of commissions paid to insurance broker | USD $13,439 | | 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 $13,439 | | Insurance broker organization code? | 3 |
|
| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
| Policy contract number | 00614664 |
| Policy instance | 3 |
| Insurance contract or identification number | 00614664 | | Number of Individuals Covered | 332 | | Insurance policy start date | 2017-10-01 | | Insurance policy end date | 2018-09-30 | | Total amount of commissions paid to insurance broker | USD $1,585 | | Total amount of fees paid to insurance company | USD $54,614 | | Health Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,974,298 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,585 | | Amount paid for insurance broker fees | 54614 | | Additional information about fees paid to insurance broker | BENEFIT ADVISOR FEE | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | SGM600844 |
| Policy instance | 4 |
| Insurance contract or identification number | SGM600844 | | Number of Individuals Covered | 339 | | Insurance policy start date | 2017-10-01 | | Insurance policy end date | 2018-09-30 | | Total amount of commissions paid to insurance broker | USD $4,719 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $31,457 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,719 | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | SOK600385 |
| Policy instance | 5 |
| Insurance contract or identification number | SOK600385 | | Number of Individuals Covered | 308 | | Insurance policy start date | 2017-10-01 | | Insurance policy end date | 2018-09-30 | | Total amount of commissions paid to insurance broker | USD $524 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $3,490 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $524 | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | SGD600709 |
| Policy instance | 6 |
| Insurance contract or identification number | SGD600709 | | Number of Individuals Covered | 275 | | Insurance policy start date | 2017-10-01 | | Insurance policy end date | 2018-09-30 | | Total amount of commissions paid to insurance broker | USD $4,895 | | Total amount of fees paid to insurance company | USD $0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $32,635 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,895 | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | SGD600709 |
| Policy instance | 6 |
| Insurance contract or identification number | SGD600709 | | Number of Individuals Covered | 275 | | Insurance policy start date | 2016-10-01 | | Insurance policy end date | 2017-09-30 | | Total amount of commissions paid to insurance broker | USD $3,853 | | Total amount of fees paid to insurance company | USD $0 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $18,906 | | 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 | SOK600385 |
| Policy instance | 5 |
| Insurance contract or identification number | SOK600385 | | Number of Individuals Covered | 308 | | Insurance policy start date | 2016-10-01 | | Insurance policy end date | 2017-09-30 | | Total amount of commissions paid to insurance broker | USD $429 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $2,091 | | 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 | SGM600844 |
| Policy instance | 4 |
| Insurance contract or identification number | SGM600844 | | Number of Individuals Covered | 339 | | Insurance policy start date | 2016-10-01 | | Insurance policy end date | 2017-09-30 | | Total amount of commissions paid to insurance broker | USD $3,935 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $19,224 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
| Policy contract number | 00614664 |
| Policy instance | 3 |
| Insurance contract or identification number | 00614664 | | Number of Individuals Covered | 330 | | Insurance policy start date | 2016-12-01 | | Insurance policy end date | 2017-11-30 | | Total amount of commissions paid to insurance broker | USD $1,788 | | Total amount of fees paid to insurance company | USD $85,825 | | Health Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $2,410,065 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| DELTA DENTAL OF TENNESSEE (National Association of Insurance Commissioners NAIC id number: 54526 ) |
| Policy contract number | 1648 |
| Policy instance | 2 |
| Insurance contract or identification number | 1648 | | Number of Individuals Covered | 540 | | Insurance policy start date | 2017-05-01 | | Insurance policy end date | 2018-04-30 | | Total amount of commissions paid to insurance broker | USD $13,386 | | 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 |
|
| COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 ) |
| Policy contract number | E9883430 |
| Policy instance | 1 |
| Insurance contract or identification number | E9883430 | | Number of Individuals Covered | 136 | | Insurance policy start date | 2017-05-01 | | Insurance policy end date | 2018-04-30 | | Total amount of commissions paid to insurance broker | USD $21,326 | | Total amount of fees paid to insurance company | USD $10,451 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $140,301 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
