FOURJAY, L.L.C. has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan FOURJAY, L.L.C. EMPLOYEE HEALTH PLAN
401k plan membership statisitcs for FOURJAY, L.L.C. EMPLOYEE HEALTH PLAN
| Measure | Date | Value |
|---|
| 2022: FOURJAY, L.L.C. EMPLOYEE HEALTH PLAN 2022 401k membership |
|---|
| Total participants, beginning-of-year | 2022-01-01 | 189 |
| Total number of active participants reported on line 7a of the Form 5500 | 2022-01-01 | 230 |
| Number of retired or separated participants receiving benefits | 2022-01-01 | 2 |
| Total of all active and inactive participants | 2022-01-01 | 232 |
| 2021: FOURJAY, L.L.C. EMPLOYEE HEALTH PLAN 2021 401k membership |
|---|
| Total participants, beginning-of-year | 2021-01-01 | 183 |
| Total number of active participants reported on line 7a of the Form 5500 | 2021-01-01 | 189 |
| Total of all active and inactive participants | 2021-01-01 | 189 |
| 2020: FOURJAY, L.L.C. EMPLOYEE HEALTH PLAN 2020 401k membership |
|---|
| Total participants, beginning-of-year | 2020-01-01 | 223 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-01-01 | 183 |
| Total of all active and inactive participants | 2020-01-01 | 183 |
| 2019: FOURJAY, L.L.C. EMPLOYEE HEALTH PLAN 2019 401k membership |
|---|
| Total participants, beginning-of-year | 2019-01-01 | 200 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-01-01 | 223 |
| Number of retired or separated participants receiving benefits | 2019-01-01 | 1 |
| Total of all active and inactive participants | 2019-01-01 | 224 |
| 2018: FOURJAY, L.L.C. EMPLOYEE HEALTH PLAN 2018 401k membership |
|---|
| Total participants, beginning-of-year | 2018-01-01 | 226 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-01-01 | 200 |
| Number of retired or separated participants receiving benefits | 2018-01-01 | 1 |
| Total of all active and inactive participants | 2018-01-01 | 201 |
| 2017: FOURJAY, L.L.C. EMPLOYEE HEALTH PLAN 2017 401k membership |
|---|
| Total participants, beginning-of-year | 2017-01-01 | 209 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-01-01 | 225 |
| Number of retired or separated participants receiving benefits | 2017-01-01 | 1 |
| Total of all active and inactive participants | 2017-01-01 | 226 |
| 2016: FOURJAY, L.L.C. EMPLOYEE HEALTH PLAN 2016 401k membership |
|---|
| Total participants, beginning-of-year | 2016-01-01 | 205 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-01-01 | 209 |
| Number of retired or separated participants receiving benefits | 2016-01-01 | 1 |
| Total of all active and inactive participants | 2016-01-01 | 210 |
| 2015: FOURJAY, L.L.C. EMPLOYEE HEALTH PLAN 2015 401k membership |
|---|
| Total participants, beginning-of-year | 2015-01-01 | 195 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-01-01 | 205 |
| Total of all active and inactive participants | 2015-01-01 | 205 |
| 2014: FOURJAY, L.L.C. EMPLOYEE HEALTH PLAN 2014 401k membership |
|---|
| Total participants, beginning-of-year | 2014-01-01 | 203 |
| Total number of active participants reported on line 7a of the Form 5500 | 2014-01-01 | 195 |
| 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 | 195 |
| 2013: FOURJAY, L.L.C. EMPLOYEE HEALTH PLAN 2013 401k membership |
|---|
| Total participants, beginning-of-year | 2013-01-01 | 203 |
| Total number of active participants reported on line 7a of the Form 5500 | 2013-01-01 | 203 |
| Total of all active and inactive participants | 2013-01-01 | 203 |
| 2012: FOURJAY, L.L.C. EMPLOYEE HEALTH PLAN 2012 401k membership |
|---|
| Total participants, beginning-of-year | 2012-01-01 | 195 |
| Total number of active participants reported on line 7a of the Form 5500 | 2012-01-01 | 203 |
| Total of all active and inactive participants | 2012-01-01 | 203 |
| 2011: FOURJAY, L.L.C. EMPLOYEE HEALTH PLAN 2011 401k membership |
|---|
| Total participants, beginning-of-year | 2011-01-01 | 198 |
| Total number of active participants reported on line 7a of the Form 5500 | 2011-01-01 | 195 |
| Total of all active and inactive participants | 2011-01-01 | 195 |
| 2010: FOURJAY, L.L.C. EMPLOYEE HEALTH PLAN 2010 401k membership |
|---|
| Total participants, beginning-of-year | 2010-01-01 | 216 |
| Total number of active participants reported on line 7a of the Form 5500 | 2010-01-01 | 198 |
| Number of retired or separated participants receiving benefits | 2010-01-01 | 0 |
| Total of all active and inactive participants | 2010-01-01 | 198 |
| 2009: FOURJAY, L.L.C. EMPLOYEE HEALTH PLAN 2009 401k membership |
|---|
| Total participants, beginning-of-year | 2009-01-01 | 216 |
| Total number of active participants reported on line 7a of the Form 5500 | 2009-01-01 | 216 |
| Number of retired or separated participants receiving benefits | 2009-01-01 | 0 |
| Total of all active and inactive participants | 2009-01-01 | 216 |
| 2022: FOURJAY, L.L.C. EMPLOYEE HEALTH PLAN 2022 form 5500 responses |
|---|
| 2022-01-01 | Type of plan entity | Mulitple employer plan |
| 2022-01-01 | Plan funding arrangement – Insurance | Yes |
| 2022-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2021: FOURJAY, L.L.C. EMPLOYEE HEALTH PLAN 2021 form 5500 responses |
|---|
| 2021-01-01 | Type of plan entity | Mulitple employer plan |
| 2021-01-01 | Plan funding arrangement – Insurance | Yes |
| 2021-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2020: FOURJAY, L.L.C. EMPLOYEE HEALTH PLAN 2020 form 5500 responses |
|---|
| 2020-01-01 | Type of plan entity | Mulitple employer plan |
| 2020-01-01 | Plan funding arrangement – Insurance | Yes |
| 2020-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2019: FOURJAY, L.L.C. EMPLOYEE HEALTH PLAN 2019 form 5500 responses |
|---|
| 2019-01-01 | Type of plan entity | Mulitple employer plan |
| 2019-01-01 | Plan funding arrangement – Insurance | Yes |
| 2019-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2018: FOURJAY, L.L.C. EMPLOYEE HEALTH PLAN 2018 form 5500 responses |
|---|
| 2018-01-01 | Type of plan entity | Mulitple employer plan |
| 2018-01-01 | Plan funding arrangement – Insurance | Yes |
| 2018-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2017: FOURJAY, L.L.C. EMPLOYEE HEALTH PLAN 2017 form 5500 responses |
|---|
| 2017-01-01 | Type of plan entity | Single employer plan |
| 2017-01-01 | Plan funding arrangement – Insurance | Yes |
| 2017-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2016: FOURJAY, L.L.C. EMPLOYEE HEALTH PLAN 2016 form 5500 responses |
|---|
| 2016-01-01 | Type of plan entity | Single employer plan |
| 2016-01-01 | Plan funding arrangement – Insurance | Yes |
| 2016-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2016-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2016-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2015: FOURJAY, L.L.C. EMPLOYEE HEALTH PLAN 2015 form 5500 responses |
|---|
| 2015-01-01 | Type of plan entity | Single employer plan |
| 2015-01-01 | Plan funding arrangement – Insurance | Yes |
| 2015-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2015-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2015-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2014: FOURJAY, L.L.C. EMPLOYEE HEALTH PLAN 2014 form 5500 responses |
|---|
| 2014-01-01 | Type of plan entity | Single employer plan |
| 2014-01-01 | Plan funding arrangement – Insurance | Yes |
| 2014-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2014-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2014-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2013: FOURJAY, L.L.C. EMPLOYEE HEALTH PLAN 2013 form 5500 responses |
|---|
| 2013-01-01 | Type of plan entity | Single employer plan |
| 2013-01-01 | Plan funding arrangement – Insurance | Yes |
| 2013-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2013-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2013-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2012: FOURJAY, L.L.C. EMPLOYEE HEALTH PLAN 2012 form 5500 responses |
|---|
| 2012-01-01 | Type of plan entity | Single employer plan |
| 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: FOURJAY, L.L.C. EMPLOYEE HEALTH PLAN 2011 form 5500 responses |
|---|
| 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: FOURJAY, L.L.C. EMPLOYEE HEALTH PLAN 2010 form 5500 responses |
|---|
| 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: FOURJAY, L.L.C. EMPLOYEE HEALTH PLAN 2009 form 5500 responses |
|---|
| 2009-01-01 | Type of plan entity | Single employer plan |
| 2009-01-01 | This submission is the final filing | No |
| 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 |
| ARKANSAS BLUE CROSS BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 83470 ) |
| Policy contract number | 028951;029020 |
| Policy instance | 3 |
| Insurance contract or identification number | 028951;029020 | | Number of Individuals Covered | 265 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000ARTF |
| Policy instance | 2 |
| Insurance contract or identification number | G000ARTF | | Number of Individuals Covered | 168 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $7,117 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $71,168 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,117 | | Additional information about fees paid to insurance broker | AGENT OF RECORD | | Insurance broker organization code? | 3 |
|
| ARKANSAS BLUE CROSS BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 83470 ) |
| Policy contract number | 027639;027718 |
| Policy instance | 1 |
| Insurance contract or identification number | 027639;027718 | | Number of Individuals Covered | 313 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | 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 |
|
| ARKANSAS BLUE CROSS BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 83470 ) |
| Policy contract number | 028951;029020 |
| Policy instance | 3 |
| Insurance contract or identification number | 028951;029020 | | Number of Individuals Covered | 290 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000ARTF |
| Policy instance | 2 |
| Insurance contract or identification number | G000ARTF | | Number of Individuals Covered | 182 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $7,231 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $72,313 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,231 | | Additional information about fees paid to insurance broker | AGENT OF RECORD | | Insurance broker organization code? | 3 |
|
| ARKANSAS BLUE CROSS BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 83470 ) |
| Policy contract number | 027639;027718 |
| Policy instance | 1 |
| Insurance contract or identification number | 027639;027718 | | Number of Individuals Covered | 296 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | 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 |
|
| ARKANSAS BLUE CROSS BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 83470 ) |
| Policy contract number | 027639;027718 |
| Policy instance | 1 |
| Insurance contract or identification number | 027639;027718 | | Number of Individuals Covered | 341 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | 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 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000ARTF |
| Policy instance | 2 |
| Insurance contract or identification number | G000ARTF | | Number of Individuals Covered | 187 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $7,154 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $71,543 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,154 | | Additional information about fees paid to insurance broker | AGENT OF RECORD | | Insurance broker organization code? | 3 |
|
| ARKANSAS BLUE CROSS BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 83470 ) |
| Policy contract number | 028951;029020 |
| Policy instance | 3 |
| Insurance contract or identification number | 028951;029020 | | Number of Individuals Covered | 278 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| ARKANSAS BLUE CROSS BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 83470 ) |
| Policy contract number | 028951;029020 |
| Policy instance | 3 |
| Insurance contract or identification number | 028951;029020 | | Number of Individuals Covered | 306 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000ARTF |
| Policy instance | 2 |
| Insurance contract or identification number | G000ARTF | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $7,844 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $78,442 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,844 | | Additional information about fees paid to insurance broker | AGENT OF RECORD | | Insurance broker organization code? | 3 |
|
| ARKANSAS BLUE CROSS BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 83470 ) |
| Policy contract number | 027639;027718 |
| Policy instance | 1 |
| Insurance contract or identification number | 027639;027718 | | Number of Individuals Covered | 342 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | 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 |
|
| ARKANSAS BLUE CROSS BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 83470 ) |
| Policy contract number | 028951;029020 |
| Policy instance | 3 |
| Insurance contract or identification number | 028951;029020 | | Number of Individuals Covered | 226 | | 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 | | Health Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Insurance broker name | NONE |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000ARTF |
| Policy instance | 2 |
| Insurance contract or identification number | G000ARTF | | Number of Individuals Covered | 217 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $8,187 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $81,870 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,187 | | Additional information about fees paid to insurance broker | AGENT OF RECORD | | Insurance broker organization code? | 3 | | Insurance broker name | HOLLIS AND BURNS INC |
|
| ARKANSAS BLUE CROSS BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 83470 ) |
| Policy contract number | 02769;027718 |
| Policy instance | 1 |
| Insurance contract or identification number | 02769;027718 | | Number of Individuals Covered | 214 | | 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 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Insurance broker name | NONE |
|
| QBE A&H (National Association of Insurance Commissioners NAIC id number: 10219 ) |
| Policy contract number | LGS00920-15 |
| Policy instance | 1 |
| Insurance contract or identification number | LGS00920-15 | | Number of Individuals Covered | 186 | | 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 | | Welfare Benefit Premiums Paid to Carrier | USD $259,153 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000ARTF |
| Policy instance | 2 |
| Insurance contract or identification number | G000ARTF | | Number of Individuals Covered | 205 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $6,821 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $68,209 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,821 | | Additional information about fees paid to insurance broker | AGENT OF RECORD | | Insurance broker organization code? | 3 | | Insurance broker name | HOLLIS AND BURNS INC |
|
| QBE A&H (National Association of Insurance Commissioners NAIC id number: 10219 ) |
| Policy contract number | LGS00920-14 |
| Policy instance | 1 |
| Insurance contract or identification number | LGS00920-14 | | Number of Individuals Covered | 147 | | 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 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Welfare Benefit Premiums Paid to Carrier | USD $218,438 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000ARTF |
| Policy instance | 2 |
| Insurance contract or identification number | G000ARTF | | Number of Individuals Covered | 195 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $6,613 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $66,126 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,613 | | Additional information about fees paid to insurance broker | AGENT OF RECORD | | Insurance broker organization code? | 3 | | Insurance broker name | HOLLIS AND BURNS, INC. |
|
| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
| Policy contract number | 034652G |
| Policy instance | 1 |
| Insurance contract or identification number | 034652G | | Number of Individuals Covered | 203 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $7,334 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $65,152 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,870 | | Insurance broker organization code? | 3 | | Insurance broker name | JP FARLEY CORPORATION |
|
| QBE A&H (National Association of Insurance Commissioners NAIC id number: 10219 ) |
| Policy contract number | LGS00920-13 |
| Policy instance | 2 |
| Insurance contract or identification number | LGS00920-13 | | Number of Individuals Covered | 135 | | 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 $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Welfare Benefit Premiums Paid to Carrier | USD $198,877 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| INTERNATIONAL INSURANCE AGENCY (National Association of Insurance Commissioners NAIC id number: 86355 ) |
| Policy contract number | IIS2142 |
| Policy instance | 2 |
| Insurance contract or identification number | IIS2142 | | Number of Individuals Covered | 131 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Welfare Benefit Premiums Paid to Carrier | USD $169,005 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
| Policy contract number | 034652G |
| Policy instance | 1 |
| Insurance contract or identification number | 034652G | | Number of Individuals Covered | 203 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $7,290 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $65,447 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,290 | | Insurance broker organization code? | 3 | | Insurance broker name | JP FARLEY CORPORATION |
|
| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
| Policy contract number | 034652G |
| Policy instance | 1 |
| Insurance contract or identification number | 034652G | | Number of Individuals Covered | 195 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2011-12-31 | | Total amount of commissions paid to insurance broker | USD $7,237 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $64,221 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| FEDERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 20281 ) |
| Policy contract number | 9906-7700-00 |
| Policy instance | 2 |
| Insurance contract or identification number | 9906-7700-00 | | Number of Individuals Covered | 138 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2011-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Welfare Benefit Premiums Paid to Carrier | USD $198,616 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
| Policy contract number | 034652G |
| Policy instance | 1 |
| Insurance contract or identification number | 034652G | | Number of Individuals Covered | 198 | | Insurance policy start date | 2010-01-01 | | Insurance policy end date | 2010-12-31 | | Total amount of commissions paid to insurance broker | USD $7,380 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $64,773 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| FEDERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 20281 ) |
| Policy contract number | 9906-42-27 |
| Policy instance | 2 |
| Insurance contract or identification number | 9906-42-27 | | Number of Individuals Covered | 160 | | Insurance policy start date | 2010-10-01 | | Insurance policy end date | 2011-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Welfare Benefit Premiums Paid to Carrier | USD $47,944 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| FEDERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 20281 ) |
| Policy contract number | 9906-42-27 |
| Policy instance | 3 |
| Insurance contract or identification number | 9906-42-27 | | Insurance policy start date | 2008-10-01 | | Insurance policy end date | 2009-09-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Welfare Benefit Premiums Paid to Carrier | USD $-55 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| NATIONAL UNION (National Association of Insurance Commissioners NAIC id number: 19445 ) |
| Policy contract number | 280-9515 |
| Policy instance | 4 |
| Insurance contract or identification number | 280-9515 | | Number of Individuals Covered | 160 | | Insurance policy start date | 2009-10-01 | | Insurance policy end date | 2010-09-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Welfare Benefit Premiums Paid to Carrier | USD $115,181 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
