HOMELAND VINYL PRODUCTS, INC has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan HOMELAND VINYL PRODUCTS, INC. EMPLOYEE BENEFIT PLAN AND TRUST
401k plan membership statisitcs for HOMELAND VINYL PRODUCTS, INC. EMPLOYEE BENEFIT PLAN AND TRUST
| Measure | Date | Value |
|---|
| 2022 : HOMELAND VINYL PRODUCTS, INC. EMPLOYEE BENEFIT PLAN AND TRUST 2022 401k financial data |
|---|
| Total income from all sources (including contributions) | 2022-12-31 | $4,403,853 |
| Total of all expenses incurred | 2022-12-31 | $4,539,509 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2022-12-31 | $4,169,078 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2022-12-31 | $4,400,000 |
| Value of total assets at end of year | 2022-12-31 | $310,393 |
| Value of total assets at beginning of year | 2022-12-31 | $446,049 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2022-12-31 | $370,431 |
| Total interest from all sources | 2022-12-31 | $3,853 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2022-12-31 | No |
| Was this plan covered by a fidelity bond | 2022-12-31 | No |
| If this is an individual account plan, was there a blackout period | 2022-12-31 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2022-12-31 | No |
| Contributions received from participants | 2022-12-31 | $1,542,870 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2022-12-31 | No |
| Value of net income/loss | 2022-12-31 | $-135,656 |
| Value of net assets at end of year (total assets less liabilities) | 2022-12-31 | $310,393 |
| Value of net assets at beginning of year (total assets less liabilities) | 2022-12-31 | $446,049 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2022-12-31 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2022-12-31 | No |
| Were any leases to which the plan was party in default or uncollectible | 2022-12-31 | No |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year | 2022-12-31 | $310,393 |
| Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year | 2022-12-31 | $446,049 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year | 2022-12-31 | $446,049 |
| Interest earned from interest bearing cash (including money market accounts and certificates of deposit) | 2022-12-31 | $3,853 |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2022-12-31 | $2,938,985 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2022-12-31 | No |
| Was there a failure to transmit to the plan any participant contributions | 2022-12-31 | No |
| Has the plan failed to provide any benefit when due under the plan | 2022-12-31 | No |
| Contributions received in cash from employer | 2022-12-31 | $2,857,130 |
| Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers | 2022-12-31 | $1,230,093 |
| Contract administrator fees | 2022-12-31 | $370,431 |
| Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-3 | 2022-12-31 | No |
| Did the plan have assets held for investment | 2022-12-31 | No |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2022-12-31 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2022-12-31 | No |
| Opinion of an independent qualified public accountant for this plan | 2022-12-31 | Unqualified |
| Accountancy firm name | 2022-12-31 | MDA PROFESSIONAL GROUP, PC |
| Accountancy firm EIN | 2022-12-31 | 630681783 |
| 2021 : HOMELAND VINYL PRODUCTS, INC. EMPLOYEE BENEFIT PLAN AND TRUST 2021 401k financial data |
|---|
| Total income from all sources (including contributions) | 2021-12-31 | $3,900,101 |
| Total of all expenses incurred | 2021-12-31 | $3,844,659 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2021-12-31 | $3,437,392 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2021-12-31 | $3,900,000 |
| Value of total assets at end of year | 2021-12-31 | $446,049 |
| Value of total assets at beginning of year | 2021-12-31 | $390,607 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2021-12-31 | $407,267 |
| Total interest from all sources | 2021-12-31 | $101 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2021-12-31 | No |
| Was this plan covered by a fidelity bond | 2021-12-31 | No |
| If this is an individual account plan, was there a blackout period | 2021-12-31 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2021-12-31 | No |
| Contributions received from participants | 2021-12-31 | $1,368,482 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2021-12-31 | No |
| Value of net income/loss | 2021-12-31 | $55,442 |
| Value of net assets at end of year (total assets less liabilities) | 2021-12-31 | $446,049 |
| Value of net assets at beginning of year (total assets less liabilities) | 2021-12-31 | $390,607 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2021-12-31 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2021-12-31 | No |
| Were any leases to which the plan was party in default or uncollectible | 2021-12-31 | No |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year | 2021-12-31 | $446,049 |
| Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year | 2021-12-31 | $390,607 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year | 2021-12-31 | $390,607 |
| Interest earned from interest bearing cash (including money market accounts and certificates of deposit) | 2021-12-31 | $101 |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2021-12-31 | $2,010,445 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2021-12-31 | No |
| Was there a failure to transmit to the plan any participant contributions | 2021-12-31 | No |
| Has the plan failed to provide any benefit when due under the plan | 2021-12-31 | No |
| Contributions received in cash from employer | 2021-12-31 | $2,531,518 |
| Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers | 2021-12-31 | $1,426,947 |
| Contract administrator fees | 2021-12-31 | $407,267 |
| Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-3 | 2021-12-31 | No |
| Did the plan have assets held for investment | 2021-12-31 | No |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2021-12-31 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2021-12-31 | No |
| Opinion of an independent qualified public accountant for this plan | 2021-12-31 | Unqualified |
| Accountancy firm name | 2021-12-31 | MDA PROFESSIONAL GROUP PC |
| Accountancy firm EIN | 2021-12-31 | 630681783 |
| 2020 : HOMELAND VINYL PRODUCTS, INC. EMPLOYEE BENEFIT PLAN AND TRUST 2020 401k financial data |
|---|
| Total income from all sources (including contributions) | 2020-12-31 | $3,650,799 |
| Total of all expenses incurred | 2020-12-31 | $3,523,590 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2020-12-31 | $3,253,650 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2020-12-31 | $3,650,000 |
| Value of total assets at end of year | 2020-12-31 | $390,607 |
| Value of total assets at beginning of year | 2020-12-31 | $263,398 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2020-12-31 | $269,940 |
| Total interest from all sources | 2020-12-31 | $799 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2020-12-31 | No |
| Was this plan covered by a fidelity bond | 2020-12-31 | No |
| If this is an individual account plan, was there a blackout period | 2020-12-31 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2020-12-31 | No |
| Contributions received from participants | 2020-12-31 | $1,274,193 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2020-12-31 | No |
| Value of net income/loss | 2020-12-31 | $127,209 |
| Value of net assets at end of year (total assets less liabilities) | 2020-12-31 | $390,607 |
| Value of net assets at beginning of year (total assets less liabilities) | 2020-12-31 | $263,398 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2020-12-31 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2020-12-31 | No |
| Were any leases to which the plan was party in default or uncollectible | 2020-12-31 | No |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year | 2020-12-31 | $390,607 |
| Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year | 2020-12-31 | $263,398 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year | 2020-12-31 | $263,398 |
| Interest earned from interest bearing cash (including money market accounts and certificates of deposit) | 2020-12-31 | $799 |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2020-12-31 | $1,920,667 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2020-12-31 | No |
| Was there a failure to transmit to the plan any participant contributions | 2020-12-31 | No |
| Has the plan failed to provide any benefit when due under the plan | 2020-12-31 | No |
| Contributions received in cash from employer | 2020-12-31 | $2,375,807 |
| Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers | 2020-12-31 | $1,332,983 |
| Contract administrator fees | 2020-12-31 | $269,940 |
| Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-3 | 2020-12-31 | No |
| Did the plan have assets held for investment | 2020-12-31 | No |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2020-12-31 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2020-12-31 | No |
| Opinion of an independent qualified public accountant for this plan | 2020-12-31 | Unqualified |
| Accountancy firm name | 2020-12-31 | MDA PROFESSIONAL GROUP PC |
| Accountancy firm EIN | 2020-12-31 | 630681783 |
| 2019 : HOMELAND VINYL PRODUCTS, INC. EMPLOYEE BENEFIT PLAN AND TRUST 2019 401k financial data |
|---|
| Total income from all sources (including contributions) | 2019-12-31 | $3,203,337 |
| Total of all expenses incurred | 2019-12-31 | $3,040,267 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2019-12-31 | $2,768,533 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2019-12-31 | $3,200,000 |
| Value of total assets at end of year | 2019-12-31 | $263,398 |
| Value of total assets at beginning of year | 2019-12-31 | $100,328 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2019-12-31 | $271,734 |
| Total interest from all sources | 2019-12-31 | $3,337 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2019-12-31 | No |
| Was this plan covered by a fidelity bond | 2019-12-31 | No |
| If this is an individual account plan, was there a blackout period | 2019-12-31 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2019-12-31 | No |
| Contributions received from participants | 2019-12-31 | $1,248,011 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2019-12-31 | No |
| Value of net income/loss | 2019-12-31 | $163,070 |
| Value of net assets at end of year (total assets less liabilities) | 2019-12-31 | $263,398 |
| Value of net assets at beginning of year (total assets less liabilities) | 2019-12-31 | $100,328 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2019-12-31 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2019-12-31 | No |
| Were any leases to which the plan was party in default or uncollectible | 2019-12-31 | No |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year | 2019-12-31 | $263,398 |
| Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year | 2019-12-31 | $100,328 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year | 2019-12-31 | $100,328 |
| Interest earned from interest bearing cash (including money market accounts and certificates of deposit) | 2019-12-31 | $3,337 |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2019-12-31 | $1,471,681 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2019-12-31 | No |
| Was there a failure to transmit to the plan any participant contributions | 2019-12-31 | No |
| Has the plan failed to provide any benefit when due under the plan | 2019-12-31 | No |
| Contributions received in cash from employer | 2019-12-31 | $1,951,989 |
| Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers | 2019-12-31 | $1,296,852 |
| Contract administrator fees | 2019-12-31 | $271,734 |
| Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-3 | 2019-12-31 | No |
| Did the plan have assets held for investment | 2019-12-31 | No |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2019-12-31 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2019-12-31 | No |
| Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d) | 2019-12-31 | No |
| Opinion of an independent qualified public accountant for this plan | 2019-12-31 | Unqualified |
| Accountancy firm name | 2019-12-31 | MDA PROFESSIONAL GROUP, P.C. |
| Accountancy firm EIN | 2019-12-31 | 630681783 |
| 2018 : HOMELAND VINYL PRODUCTS, INC. EMPLOYEE BENEFIT PLAN AND TRUST 2018 401k financial data |
|---|
| Total income from all sources (including contributions) | 2018-12-31 | $3,252,244 |
| Total of all expenses incurred | 2018-12-31 | $3,303,905 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2018-12-31 | $3,007,044 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2018-12-31 | $3,250,000 |
| Value of total assets at end of year | 2018-12-31 | $100,328 |
| Value of total assets at beginning of year | 2018-12-31 | $151,989 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2018-12-31 | $296,861 |
| Total interest from all sources | 2018-12-31 | $2,244 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2018-12-31 | No |
| Was this plan covered by a fidelity bond | 2018-12-31 | No |
| If this is an individual account plan, was there a blackout period | 2018-12-31 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2018-12-31 | No |
| Contributions received from participants | 2018-12-31 | $1,837,764 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2018-12-31 | No |
| Value of net income/loss | 2018-12-31 | $-51,661 |
| Value of net assets at end of year (total assets less liabilities) | 2018-12-31 | $100,328 |
| Value of net assets at beginning of year (total assets less liabilities) | 2018-12-31 | $151,989 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2018-12-31 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2018-12-31 | No |
| Were any leases to which the plan was party in default or uncollectible | 2018-12-31 | No |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year | 2018-12-31 | $100,328 |
| Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year | 2018-12-31 | $151,989 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year | 2018-12-31 | $151,989 |
| Interest earned from interest bearing cash (including money market accounts and certificates of deposit) | 2018-12-31 | $2,244 |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2018-12-31 | $1,468,999 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2018-12-31 | No |
| Was there a failure to transmit to the plan any participant contributions | 2018-12-31 | No |
| Has the plan failed to provide any benefit when due under the plan | 2018-12-31 | No |
| Contributions received in cash from employer | 2018-12-31 | $1,412,236 |
| Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers | 2018-12-31 | $1,538,045 |
| Contract administrator fees | 2018-12-31 | $296,861 |
| Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-3 | 2018-12-31 | No |
| Did the plan have assets held for investment | 2018-12-31 | No |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2018-12-31 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2018-12-31 | No |
| Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d) | 2018-12-31 | No |
| Opinion of an independent qualified public accountant for this plan | 2018-12-31 | Unqualified |
| Accountancy firm name | 2018-12-31 | MDA PROFESSIONAL GROUP, P.C. |
| Accountancy firm EIN | 2018-12-31 | 630681783 |
| 2017 : HOMELAND VINYL PRODUCTS, INC. EMPLOYEE BENEFIT PLAN AND TRUST 2017 401k financial data |
|---|
| Total income from all sources (including contributions) | 2017-12-31 | $2,675,644 |
| Total of all expenses incurred | 2017-12-31 | $2,673,863 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2017-12-31 | $2,469,934 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2017-12-31 | $2,675,000 |
| Value of total assets at end of year | 2017-12-31 | $151,989 |
| Value of total assets at beginning of year | 2017-12-31 | $150,208 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2017-12-31 | $203,929 |
| Total interest from all sources | 2017-12-31 | $644 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2017-12-31 | No |
| Was this plan covered by a fidelity bond | 2017-12-31 | No |
| If this is an individual account plan, was there a blackout period | 2017-12-31 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2017-12-31 | No |
| Contributions received from participants | 2017-12-31 | $1,401,849 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2017-12-31 | No |
| Value of net income/loss | 2017-12-31 | $1,781 |
| Value of net assets at end of year (total assets less liabilities) | 2017-12-31 | $151,989 |
| Value of net assets at beginning of year (total assets less liabilities) | 2017-12-31 | $150,208 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2017-12-31 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2017-12-31 | No |
| Were any leases to which the plan was party in default or uncollectible | 2017-12-31 | No |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year | 2017-12-31 | $151,989 |
| Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year | 2017-12-31 | $150,208 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year | 2017-12-31 | $150,208 |
| Interest earned from interest bearing cash (including money market accounts and certificates of deposit) | 2017-12-31 | $644 |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2017-12-31 | $872,341 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2017-12-31 | No |
| Was there a failure to transmit to the plan any participant contributions | 2017-12-31 | No |
| Has the plan failed to provide any benefit when due under the plan | 2017-12-31 | No |
| Contributions received in cash from employer | 2017-12-31 | $1,273,151 |
| Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers | 2017-12-31 | $1,597,593 |
| Contract administrator fees | 2017-12-31 | $203,929 |
| Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-3 | 2017-12-31 | No |
| Did the plan have assets held for investment | 2017-12-31 | No |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2017-12-31 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2017-12-31 | No |
| Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d) | 2017-12-31 | No |
| Opinion of an independent qualified public accountant for this plan | 2017-12-31 | Unqualified |
| Accountancy firm name | 2017-12-31 | MDA PROFESSIONAL GROUP, P.C. |
| Accountancy firm EIN | 2017-12-31 | 630681783 |
| 2016 : HOMELAND VINYL PRODUCTS, INC. EMPLOYEE BENEFIT PLAN AND TRUST 2016 401k financial data |
|---|
| Total income from all sources (including contributions) | 2016-12-31 | $2,250,004 |
| Total of all expenses incurred | 2016-12-31 | $2,209,321 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2016-12-31 | $2,078,330 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2016-12-31 | $2,250,001 |
| Value of total assets at end of year | 2016-12-31 | $150,208 |
| Value of total assets at beginning of year | 2016-12-31 | $109,525 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2016-12-31 | $130,991 |
| Total interest from all sources | 2016-12-31 | $3 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2016-12-31 | No |
| Was this plan covered by a fidelity bond | 2016-12-31 | No |
| If this is an individual account plan, was there a blackout period | 2016-12-31 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2016-12-31 | No |
| Contributions received from participants | 2016-12-31 | $1,165,118 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2016-12-31 | No |
| Value of net income/loss | 2016-12-31 | $40,683 |
| Value of net assets at end of year (total assets less liabilities) | 2016-12-31 | $150,208 |
| Value of net assets at beginning of year (total assets less liabilities) | 2016-12-31 | $109,525 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2016-12-31 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2016-12-31 | No |
| Were any leases to which the plan was party in default or uncollectible | 2016-12-31 | No |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year | 2016-12-31 | $150,208 |
| Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year | 2016-12-31 | $109,525 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year | 2016-12-31 | $109,525 |
| Interest earned from interest bearing cash (including money market accounts and certificates of deposit) | 2016-12-31 | $3 |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2016-12-31 | $737,104 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2016-12-31 | No |
| Was there a failure to transmit to the plan any participant contributions | 2016-12-31 | No |
| Has the plan failed to provide any benefit when due under the plan | 2016-12-31 | No |
| Contributions received in cash from employer | 2016-12-31 | $1,084,883 |
| Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers | 2016-12-31 | $1,341,226 |
| Contract administrator fees | 2016-12-31 | $130,991 |
| Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-3 | 2016-12-31 | No |
| Did the plan have assets held for investment | 2016-12-31 | No |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2016-12-31 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2016-12-31 | No |
| Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d) | 2016-12-31 | No |
| Opinion of an independent qualified public accountant for this plan | 2016-12-31 | Unqualified |
| Accountancy firm name | 2016-12-31 | MDA PROFESSIONAL GROUP, P.C. |
| Accountancy firm EIN | 2016-12-31 | 630681783 |
| 2015 : HOMELAND VINYL PRODUCTS, INC. EMPLOYEE BENEFIT PLAN AND TRUST 2015 401k financial data |
|---|
| Total unrealized appreciation/depreciation of assets | 2015-12-31 | $0 |
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2015-12-31 | $0 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2015-12-31 | $0 |
| Total income from all sources (including contributions) | 2015-12-31 | $1,950,004 |
| Total loss/gain on sale of assets | 2015-12-31 | $0 |
| Total of all expenses incurred | 2015-12-31 | $1,911,552 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2015-12-31 | $1,789,810 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2015-12-31 | $1,950,000 |
| Value of total assets at end of year | 2015-12-31 | $87,538 |
| Value of total assets at beginning of year | 2015-12-31 | $49,086 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2015-12-31 | $121,742 |
| Total interest from all sources | 2015-12-31 | $4 |
| Total dividends received (eg from common stock, registered investment company shares) | 2015-12-31 | $0 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2015-12-31 | No |
| Was this plan covered by a fidelity bond | 2015-12-31 | No |
| If this is an individual account plan, was there a blackout period | 2015-12-31 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2015-12-31 | No |
| Contributions received from participants | 2015-12-31 | $1,051,259 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2015-12-31 | No |
| Value of net income/loss | 2015-12-31 | $38,452 |
| Value of net assets at end of year (total assets less liabilities) | 2015-12-31 | $87,538 |
| Value of net assets at beginning of year (total assets less liabilities) | 2015-12-31 | $49,086 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2015-12-31 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2015-12-31 | No |
| Were any leases to which the plan was party in default or uncollectible | 2015-12-31 | No |
| Investment advisory and management fees | 2015-12-31 | $200 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year | 2015-12-31 | $87,538 |
| Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year | 2015-12-31 | $49,086 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year | 2015-12-31 | $49,086 |
| Interest earned from interest bearing cash (including money market accounts and certificates of deposit) | 2015-12-31 | $4 |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2015-12-31 | $593,693 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2015-12-31 | No |
| Was there a failure to transmit to the plan any participant contributions | 2015-12-31 | No |
| Has the plan failed to provide any benefit when due under the plan | 2015-12-31 | No |
| Contributions received in cash from employer | 2015-12-31 | $898,741 |
| Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers | 2015-12-31 | $1,196,117 |
| Contract administrator fees | 2015-12-31 | $121,542 |
| Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-3 | 2015-12-31 | No |
| Did the plan have assets held for investment | 2015-12-31 | No |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2015-12-31 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2015-12-31 | No |
| Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d) | 2015-12-31 | No |
| Opinion of an independent qualified public accountant for this plan | 2015-12-31 | Unqualified |
| Accountancy firm name | 2015-12-31 | FROST & COMPANY, LLC |
| Accountancy firm EIN | 2015-12-31 | 273357055 |
| 2014 : HOMELAND VINYL PRODUCTS, INC. EMPLOYEE BENEFIT PLAN AND TRUST 2014 401k financial data |
|---|
| Total unrealized appreciation/depreciation of assets | 2014-12-31 | $0 |
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2014-12-31 | $0 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2014-12-31 | $0 |
| Total income from all sources (including contributions) | 2014-12-31 | $2,100,006 |
| Total loss/gain on sale of assets | 2014-12-31 | $0 |
| Total of all expenses incurred | 2014-12-31 | $2,093,057 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2014-12-31 | $1,926,241 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2014-12-31 | $2,100,000 |
| Value of total assets at end of year | 2014-12-31 | $49,086 |
| Value of total assets at beginning of year | 2014-12-31 | $42,137 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2014-12-31 | $166,816 |
| Total interest from all sources | 2014-12-31 | $6 |
| Total dividends received (eg from common stock, registered investment company shares) | 2014-12-31 | $0 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2014-12-31 | No |
| Was this plan covered by a fidelity bond | 2014-12-31 | No |
| If this is an individual account plan, was there a blackout period | 2014-12-31 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2014-12-31 | No |
| Contributions received from participants | 2014-12-31 | $817,924 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2014-12-31 | No |
| Value of net income/loss | 2014-12-31 | $6,949 |
| Value of net assets at end of year (total assets less liabilities) | 2014-12-31 | $49,086 |
| Value of net assets at beginning of year (total assets less liabilities) | 2014-12-31 | $42,137 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2014-12-31 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2014-12-31 | No |
| Were any leases to which the plan was party in default or uncollectible | 2014-12-31 | No |
| Investment advisory and management fees | 2014-12-31 | $150 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year | 2014-12-31 | $49,086 |
| Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year | 2014-12-31 | $42,137 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year | 2014-12-31 | $42,137 |
| Interest earned from interest bearing cash (including money market accounts and certificates of deposit) | 2014-12-31 | $6 |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2014-12-31 | $405,590 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2014-12-31 | No |
| Was there a failure to transmit to the plan any participant contributions | 2014-12-31 | No |
| Has the plan failed to provide any benefit when due under the plan | 2014-12-31 | No |
| Contributions received in cash from employer | 2014-12-31 | $1,282,076 |
| Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers | 2014-12-31 | $1,520,651 |
| Contract administrator fees | 2014-12-31 | $166,666 |
| Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-3 | 2014-12-31 | No |
| Did the plan have assets held for investment | 2014-12-31 | No |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2014-12-31 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2014-12-31 | No |
| Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d) | 2014-12-31 | No |
| Opinion of an independent qualified public accountant for this plan | 2014-12-31 | Disclaimer |
| Accountancy firm name | 2014-12-31 | FROST & COMPANY, LLC |
| Accountancy firm EIN | 2014-12-31 | 273357055 |
| 2013 : HOMELAND VINYL PRODUCTS, INC. EMPLOYEE BENEFIT PLAN AND TRUST 2013 401k financial data |
|---|
| Total unrealized appreciation/depreciation of assets | 2013-12-31 | $0 |
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2013-12-31 | $0 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2013-12-31 | $0 |
| Total income from all sources (including contributions) | 2013-12-31 | $1,835,007 |
| Total loss/gain on sale of assets | 2013-12-31 | $0 |
| Total of all expenses incurred | 2013-12-31 | $1,854,866 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2013-12-31 | $1,708,882 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2013-12-31 | $1,835,000 |
| Value of total assets at end of year | 2013-12-31 | $42,137 |
| Value of total assets at beginning of year | 2013-12-31 | $61,996 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2013-12-31 | $145,984 |
| Total interest from all sources | 2013-12-31 | $7 |
| Total dividends received (eg from common stock, registered investment company shares) | 2013-12-31 | $0 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2013-12-31 | No |
| Was this plan covered by a fidelity bond | 2013-12-31 | No |
| If this is an individual account plan, was there a blackout period | 2013-12-31 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2013-12-31 | No |
| Contributions received from participants | 2013-12-31 | $583,807 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2013-12-31 | No |
| Value of net income/loss | 2013-12-31 | $-19,859 |
| Value of net assets at end of year (total assets less liabilities) | 2013-12-31 | $42,137 |
| Value of net assets at beginning of year (total assets less liabilities) | 2013-12-31 | $61,996 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2013-12-31 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2013-12-31 | No |
| Were any leases to which the plan was party in default or uncollectible | 2013-12-31 | No |
| Investment advisory and management fees | 2013-12-31 | $150 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year | 2013-12-31 | $42,137 |
| Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year | 2013-12-31 | $61,996 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year | 2013-12-31 | $61,996 |
| Interest earned from interest bearing cash (including money market accounts and certificates of deposit) | 2013-12-31 | $7 |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2013-12-31 | $407,641 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2013-12-31 | No |
| Was there a failure to transmit to the plan any participant contributions | 2013-12-31 | No |
| Has the plan failed to provide any benefit when due under the plan | 2013-12-31 | No |
| Contributions received in cash from employer | 2013-12-31 | $1,251,193 |
| Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers | 2013-12-31 | $1,301,241 |
| Contract administrator fees | 2013-12-31 | $145,834 |
| Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-3 | 2013-12-31 | No |
| Did the plan have assets held for investment | 2013-12-31 | No |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2013-12-31 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2013-12-31 | No |
| Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d) | 2013-12-31 | No |
| Opinion of an independent qualified public accountant for this plan | 2013-12-31 | Disclaimer |
| Accountancy firm name | 2013-12-31 | FROST & COMPANY, LLC |
| Accountancy firm EIN | 2013-12-31 | 273357055 |
| 2012 : HOMELAND VINYL PRODUCTS, INC. EMPLOYEE BENEFIT PLAN AND TRUST 2012 401k financial data |
|---|
| Total income from all sources (including contributions) | 2012-12-31 | $1,710,003 |
| Total of all expenses incurred | 2012-12-31 | $1,706,893 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2012-12-31 | $1,572,798 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2012-12-31 | $1,710,000 |
| Value of total assets at end of year | 2012-12-31 | $61,996 |
| Value of total assets at beginning of year | 2012-12-31 | $58,886 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2012-12-31 | $134,095 |
| Total interest from all sources | 2012-12-31 | $3 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2012-12-31 | No |
| Was this plan covered by a fidelity bond | 2012-12-31 | No |
| If this is an individual account plan, was there a blackout period | 2012-12-31 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2012-12-31 | No |
| Contributions received from participants | 2012-12-31 | $518,408 |
| Administrative expenses (other) incurred | 2012-12-31 | $60 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2012-12-31 | No |
| Value of net income/loss | 2012-12-31 | $3,110 |
| Value of net assets at end of year (total assets less liabilities) | 2012-12-31 | $61,996 |
| Value of net assets at beginning of year (total assets less liabilities) | 2012-12-31 | $58,886 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2012-12-31 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2012-12-31 | No |
| Were any leases to which the plan was party in default or uncollectible | 2012-12-31 | No |
| Investment advisory and management fees | 2012-12-31 | $150 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year | 2012-12-31 | $61,996 |
| Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year | 2012-12-31 | $58,886 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year | 2012-12-31 | $58,886 |
| Interest earned from interest bearing cash (including money market accounts and certificates of deposit) | 2012-12-31 | $3 |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2012-12-31 | $355,683 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2012-12-31 | No |
| Was there a failure to transmit to the plan any participant contributions | 2012-12-31 | No |
| Has the plan failed to provide any benefit when due under the plan | 2012-12-31 | No |
| Contributions received in cash from employer | 2012-12-31 | $1,191,592 |
| Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers | 2012-12-31 | $1,217,115 |
| Contract administrator fees | 2012-12-31 | $133,885 |
| Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-3 | 2012-12-31 | No |
| Did the plan have assets held for investment | 2012-12-31 | No |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2012-12-31 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2012-12-31 | No |
| Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d) | 2012-12-31 | No |
| Opinion of an independent qualified public accountant for this plan | 2012-12-31 | Disclaimer |
| Accountancy firm name | 2012-12-31 | FROST & COMPANY LLC |
| Accountancy firm EIN | 2012-12-31 | 273357055 |
| 2011 : HOMELAND VINYL PRODUCTS, INC. EMPLOYEE BENEFIT PLAN AND TRUST 2011 401k financial data |
|---|
| Total income from all sources (including contributions) | 2011-12-31 | $1,400,012 |
| Total of all expenses incurred | 2011-12-31 | $1,423,578 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2011-12-31 | $1,310,127 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2011-12-31 | $1,400,000 |
| Value of total assets at end of year | 2011-12-31 | $58,886 |
| Value of total assets at beginning of year | 2011-12-31 | $82,452 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2011-12-31 | $113,451 |
| Total interest from all sources | 2011-12-31 | $12 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2011-12-31 | No |
| Was this plan covered by a fidelity bond | 2011-12-31 | No |
| If this is an individual account plan, was there a blackout period | 2011-12-31 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2011-12-31 | No |
| Contributions received from participants | 2011-12-31 | $491,824 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2011-12-31 | No |
| Value of net income/loss | 2011-12-31 | $-23,566 |
| Value of net assets at end of year (total assets less liabilities) | 2011-12-31 | $58,886 |
| Value of net assets at beginning of year (total assets less liabilities) | 2011-12-31 | $82,452 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2011-12-31 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2011-12-31 | No |
| Were any leases to which the plan was party in default or uncollectible | 2011-12-31 | No |
| Investment advisory and management fees | 2011-12-31 | $150 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year | 2011-12-31 | $58,886 |
| Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year | 2011-12-31 | $82,452 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year | 2011-12-31 | $82,452 |
| Interest earned from interest bearing cash (including money market accounts and certificates of deposit) | 2011-12-31 | $12 |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2011-12-31 | $282,204 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2011-12-31 | No |
| Was there a failure to transmit to the plan any participant contributions | 2011-12-31 | No |
| Has the plan failed to provide any benefit when due under the plan | 2011-12-31 | No |
| Contributions received in cash from employer | 2011-12-31 | $908,176 |
| Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers | 2011-12-31 | $1,027,923 |
| Contract administrator fees | 2011-12-31 | $113,301 |
| Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-3 | 2011-12-31 | No |
| Did the plan have assets held for investment | 2011-12-31 | No |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2011-12-31 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2011-12-31 | No |
| Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d) | 2011-12-31 | No |
| Opinion of an independent qualified public accountant for this plan | 2011-12-31 | Disclaimer |
| Accountancy firm name | 2011-12-31 | FROST & COMPANY LLC |
| Accountancy firm EIN | 2011-12-31 | 273357055 |
| 2010 : HOMELAND VINYL PRODUCTS, INC. EMPLOYEE BENEFIT PLAN AND TRUST 2010 401k financial data |
|---|
| Total income from all sources (including contributions) | 2010-12-31 | $1,546,589 |
| Total of all expenses incurred | 2010-12-31 | $1,521,106 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2010-12-31 | $1,399,574 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2010-12-31 | $1,546,564 |
| Value of total assets at end of year | 2010-12-31 | $82,452 |
| Value of total assets at beginning of year | 2010-12-31 | $56,969 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2010-12-31 | $121,532 |
| Total interest from all sources | 2010-12-31 | $25 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2010-12-31 | No |
| Was this plan covered by a fidelity bond | 2010-12-31 | No |
| If this is an individual account plan, was there a blackout period | 2010-12-31 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2010-12-31 | No |
| Contributions received from participants | 2010-12-31 | $512,375 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2010-12-31 | No |
| Value of net income/loss | 2010-12-31 | $25,483 |
| Value of net assets at end of year (total assets less liabilities) | 2010-12-31 | $82,452 |
| Value of net assets at beginning of year (total assets less liabilities) | 2010-12-31 | $56,969 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2010-12-31 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2010-12-31 | No |
| Were any leases to which the plan was party in default or uncollectible | 2010-12-31 | No |
| Investment advisory and management fees | 2010-12-31 | $150 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year | 2010-12-31 | $82,452 |
| Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year | 2010-12-31 | $56,969 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year | 2010-12-31 | $56,969 |
| Interest earned from interest bearing cash (including money market accounts and certificates of deposit) | 2010-12-31 | $25 |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2010-12-31 | $322,066 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2010-12-31 | No |
| Was there a failure to transmit to the plan any participant contributions | 2010-12-31 | No |
| Has the plan failed to provide any benefit when due under the plan | 2010-12-31 | No |
| Contributions received in cash from employer | 2010-12-31 | $1,034,189 |
| Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers | 2010-12-31 | $1,077,508 |
| Contract administrator fees | 2010-12-31 | $121,382 |
| Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-3 | 2010-12-31 | No |
| Did the plan have assets held for investment | 2010-12-31 | No |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2010-12-31 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2010-12-31 | No |
| Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d) | 2010-12-31 | No |
| Opinion of an independent qualified public accountant for this plan | 2010-12-31 | Disclaimer |
| Accountancy firm name | 2010-12-31 | FROST & COMPANY, LLC |
| Accountancy firm EIN | 2010-12-31 | 273357055 |
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUNJ0BCBZ |
| Policy instance | 6 |
| Insurance contract or identification number | GUNJ0BCBZ | | Number of Individuals Covered | 64 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2023-01-01 | | Total amount of commissions paid to insurance broker | USD $4,453 | | Total amount of fees paid to insurance company | USD $0 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $29,685 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,280 | | Additional information about fees paid to insurance broker | AGENT OR BROKER | | Insurance broker organization code? | 3 |
|
| AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 ) |
| Policy contract number | 37212 |
| Policy instance | 14 |
| Insurance contract or identification number | 37212 | | Number of Individuals Covered | 342 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $989 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $35,569 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $712 | | Insurance broker organization code? | 3 |
|
| COMPANION LIFE (National Association of Insurance Commissioners NAIC id number: 77828 ) |
| Policy contract number | CLI-SUM20198-02 |
| Policy instance | 1 |
| Insurance contract or identification number | CLI-SUM20198-02 | | Number of Individuals Covered | 221 | | 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 | | Welfare Benefit Premiums Paid to Carrier | USD $365,381 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| BLUE CROSS BLUE SHIELD OF ALABAMA (National Association of Insurance Commissioners NAIC id number: 55433 ) |
| Policy contract number | 46181 |
| Policy instance | 2 |
| Insurance contract or identification number | 46181 | | Number of Individuals Covered | 387 | | 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 | | Insurance broker organization code? | 1 |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 909070 |
| Policy instance | 3 |
| Insurance contract or identification number | 909070 | | Number of Individuals Covered | 584 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $10,602 | | Total amount of fees paid to insurance company | USD $51,227 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,714,168 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $10,602 | | Amount paid for insurance broker fees | 51227 | | Additional information about fees paid to insurance broker | SERVICE FEE AGREEMENT | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG0BCBZ |
| Policy instance | 4 |
| Insurance contract or identification number | GLUG0BCBZ | | Number of Individuals Covered | 550 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $3,938 | | Total amount of fees paid to insurance company | USD $4,404 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $26,256 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 3326 | | Additional information about fees paid to insurance broker | ADMINISTRATION | | Insurance broker organization code? | 5 | | Commission paid to Insurance Broker | USD $2,952 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUG 0BCBZ |
| Policy instance | 5 |
| Insurance contract or identification number | GUG 0BCBZ | | Number of Individuals Covered | 487 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2023-01-01 | | Total amount of commissions paid to insurance broker | USD $6,670 | | Total amount of fees paid to insurance company | USD $6,601 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $44,468 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,003 | | Amount paid for insurance broker fees | 3673 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GVTL0BCBZ |
| Policy instance | 7 |
| Insurance contract or identification number | GVTL0BCBZ | | Number of Individuals Covered | 125 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2023-01-01 | | Total amount of commissions paid to insurance broker | USD $9,947 | | Total amount of fees paid to insurance company | USD $4,506 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $66,311 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,510 | | Additional information about fees paid to insurance broker | AGENT OR BROKER | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 2952 |
|
| AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 ) |
| Policy contract number | 37212 |
| Policy instance | 13 |
| Insurance contract or identification number | 37212 | | Number of Individuals Covered | 331 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $4,958 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $64,745 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,669 | | Insurance broker organization code? | 3 |
|
| AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 ) |
| Policy contract number | 37212 |
| Policy instance | 12 |
| Insurance contract or identification number | 37212 | | Number of Individuals Covered | 214 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $8,456 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $81,776 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,797 | | Insurance broker organization code? | 3 |
|
| AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 ) |
| Policy contract number | 37212 |
| Policy instance | 11 |
| Insurance contract or identification number | 37212 | | Number of Individuals Covered | 686 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $9,282 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $143,708 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,448 | | Insurance broker organization code? | 5 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUPR0BCBZ |
| Policy instance | 10 |
| Insurance contract or identification number | GUPR0BCBZ | | Number of Individuals Covered | 259 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2023-01-01 | | Total amount of commissions paid to insurance broker | USD $12,184 | | Total amount of fees paid to insurance company | USD $6,615 | | Welfare Benefit Premiums Paid to Carrier | USD $81,224 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $9,828 | | Additional information about fees paid to insurance broker | AGENT | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 3621 |
|
| ACE AMERICAN INSURANCE CO (National Association of Insurance Commissioners NAIC id number: 22667 ) |
| Policy contract number | MDX N18018184 |
| Policy instance | 9 |
| Insurance contract or identification number | MDX N18018184 | | Number of Individuals Covered | 184 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $40,986 | | Total amount of fees paid to insurance company | USD $22,545 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $240,831 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $20,492 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 12294 | | Additional information about fees paid to insurance broker | SERVICE FEE |
|
| STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 ) |
| Policy contract number | 757730 |
| Policy instance | 8 |
| Insurance contract or identification number | 757730 | | Number of Individuals Covered | 369 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $4,586 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,586 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUNJ0BCBZ |
| Policy instance | 6 |
| Insurance contract or identification number | GUNJ0BCBZ | | Number of Individuals Covered | 54 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2022-01-01 | | Total amount of commissions paid to insurance broker | USD $3,835 | | Total amount of fees paid to insurance company | USD $0 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $25,568 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,835 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUG 0BCBZ |
| Policy instance | 5 |
| Insurance contract or identification number | GUG 0BCBZ | | Number of Individuals Covered | 479 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2022-01-01 | | Total amount of commissions paid to insurance broker | USD $6,454 | | Total amount of fees paid to insurance company | USD $2,820 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $43,024 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,454 | | Additional information about fees paid to insurance broker | AGENT OR BROKER OF RECORD | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 2820 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG0BCBZ |
| Policy instance | 4 |
| Insurance contract or identification number | GLUG0BCBZ | | Number of Individuals Covered | 535 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $3,781 | | Total amount of fees paid to insurance company | USD $3,198 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $25,208 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,781 | | Amount paid for insurance broker fees | 3198 | | Additional information about fees paid to insurance broker | ADMINISTRATION | | Insurance broker organization code? | 5 |
|
| AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 ) |
| Policy contract number | 37212 |
| Policy instance | 13 |
| Insurance contract or identification number | 37212 | | Number of Individuals Covered | 145 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $14,145 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $16,619 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $13,393 |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 02W4986 |
| Policy instance | 3 |
| Insurance contract or identification number | 02W4986 | | Number of Individuals Covered | 436 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $10,359 | | Total amount of fees paid to insurance company | USD $56,933 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,471,233 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $10,359 | | Amount paid for insurance broker fees | 56933 | | Additional information about fees paid to insurance broker | SERVICE FEE AGREEMENT | | Insurance broker organization code? | 3 |
|
| BLUE CROSS BLUE SHIELD OF ALABAMA (National Association of Insurance Commissioners NAIC id number: 55433 ) |
| Policy contract number | 46181 |
| Policy instance | 2 |
| Insurance contract or identification number | 46181 | | Number of Individuals Covered | 227 | | 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 | | Insurance broker organization code? | 1 |
|
| COMPANION LIFE (National Association of Insurance Commissioners NAIC id number: 77828 ) |
| Policy contract number | CLI-SUM20198-02 |
| Policy instance | 1 |
| Insurance contract or identification number | CLI-SUM20198-02 | | Number of Individuals Covered | 216 | | 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 | | Welfare Benefit Premiums Paid to Carrier | USD $263,597 | | 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 | GVTL0BCBZ |
| Policy instance | 7 |
| Insurance contract or identification number | GVTL0BCBZ | | Number of Individuals Covered | 129 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2022-01-01 | | Total amount of commissions paid to insurance broker | USD $10,312 | | Total amount of fees paid to insurance company | USD $2,034 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $68,745 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $10,312 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 2034 | | Additional information about fees paid to insurance broker | ADMINISTRATION |
|
| COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 ) |
| Policy contract number | E4894531 |
| Policy instance | 8 |
| Insurance contract or identification number | E4894531 | | 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 $16,968 | | Total amount of fees paid to insurance company | USD $1,640 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $88,328 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $16,968 | | Amount paid for insurance broker fees | 1640 |
|
| AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 ) |
| Policy contract number | 37212 |
| Policy instance | 15 |
| Insurance contract or identification number | 37212 | | Number of Individuals Covered | 279 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $7,012 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $8,221 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,848 |
|
| AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 ) |
| Policy contract number | 37212 |
| Policy instance | 14 |
| Insurance contract or identification number | 37212 | | Number of Individuals Covered | 206 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $8,036 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $13,246 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,772 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUPR0BCBZ |
| Policy instance | 11 |
| Insurance contract or identification number | GUPR0BCBZ | | Number of Individuals Covered | 242 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2022-01-01 | | Total amount of commissions paid to insurance broker | USD $12,760 | | Total amount of fees paid to insurance company | USD $2,994 | | Welfare Benefit Premiums Paid to Carrier | USD $85,064 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $12,760 | | Additional information about fees paid to insurance broker | AGENT OR BROKER OF RECORD | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 2994 |
|
| ACE AMERICAN INSURANCE CO (National Association of Insurance Commissioners NAIC id number: 22667 ) |
| Policy contract number | MDX N18018184 |
| Policy instance | 10 |
| Insurance contract or identification number | MDX N18018184 | | Number of Individuals Covered | 190 | | Insurance policy start date | 2021-05-01 | | Insurance policy end date | 2022-04-30 | | Total amount of commissions paid to insurance broker | USD $34,236 | | Total amount of fees paid to insurance company | USD $18,831 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $222,424 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $17,115 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 10271 | | Additional information about fees paid to insurance broker | SERVICE FEE |
|
| STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 ) |
| Policy contract number | 757730 |
| Policy instance | 9 |
| Insurance contract or identification number | 757730 | | Number of Individuals Covered | 357 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $4,126 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,126 | | Insurance broker organization code? | 3 |
|
| AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 ) |
| Policy contract number | 37212 |
| Policy instance | 12 |
| Insurance contract or identification number | 37212 | | Number of Individuals Covered | 607 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $29,822 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $35,887 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $28,457 |
|
| COMPANION LIFE (National Association of Insurance Commissioners NAIC id number: 77828 ) |
| Policy contract number | CLI-SUM20198-01 |
| Policy instance | 1 |
| Insurance contract or identification number | CLI-SUM20198-01 | | Number of Individuals Covered | 231 | | 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 | | Welfare Benefit Premiums Paid to Carrier | USD $251,783 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| BLUE CROSS BLUE SHIELD OF ALABAMA (National Association of Insurance Commissioners NAIC id number: 55433 ) |
| Policy contract number | 46181 |
| Policy instance | 2 |
| Insurance contract or identification number | 46181 | | Number of Individuals Covered | 366 | | 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 | | Insurance broker organization code? | 1 |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 02W4986 |
| Policy instance | 3 |
| Insurance contract or identification number | 02W4986 | | Number of Individuals Covered | 210 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-04-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $22,230 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $386,102 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 22230 |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 0909070 |
| Policy instance | 4 |
| Insurance contract or identification number | 0909070 | | Number of Individuals Covered | 226 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $8,654 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $838,418 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,654 | | Insurance broker organization code? | 4 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG0BCBZ |
| Policy instance | 5 |
| Insurance contract or identification number | GLUG0BCBZ | | Number of Individuals Covered | 1019 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $2,993 | | Total amount of fees paid to insurance company | USD $3,558 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $23,720 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,993 | | Amount paid for insurance broker fees | 3558 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUNJ0BCBZ |
| Policy instance | 7 |
| Insurance contract or identification number | GUNJ0BCBZ | | Number of Individuals Covered | 138 | | 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 $4,177 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $27,845 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 4177 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUG 0BCBZ |
| Policy instance | 6 |
| Insurance contract or identification number | GUG 0BCBZ | | Number of Individuals Covered | 877 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $5,891 | | Total amount of fees paid to insurance company | USD $2,554 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $39,277 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,891 | | Amount paid for insurance broker fees | 2554 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUPR0BCBZ |
| Policy instance | 12 |
| Insurance contract or identification number | GUPR0BCBZ | | Number of Individuals Covered | 426 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $12,883 | | Total amount of fees paid to insurance company | USD $2,994 | | Welfare Benefit Premiums Paid to Carrier | USD $85,886 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $12,883 | | Amount paid for insurance broker fees | 2994 |
|
| STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 ) |
| Policy contract number | 757730 |
| Policy instance | 10 |
| Insurance contract or identification number | 757730 | | Number of Individuals Covered | 342 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $4,345 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $37,512 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,345 | | Insurance broker organization code? | 3 |
|
| COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 ) |
| Policy contract number | E4894531 |
| Policy instance | 9 |
| Insurance contract or identification number | E4894531 | | Number of Individuals Covered | 298 | | Insurance policy start date | 2020-05-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $35,751 | | Total amount of fees paid to insurance company | USD $5,570 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $140,509 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $35,751 | | Amount paid for insurance broker fees | 5570 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GVTL0BCBZ |
| Policy instance | 8 |
| Insurance contract or identification number | GVTL0BCBZ | | Number of Individuals Covered | 282 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $9,902 | | Total amount of fees paid to insurance company | USD $2,994 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $42,510 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $9,902 | | Amount paid for insurance broker fees | 2994 | | Insurance broker organization code? | 3 |
|
| STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 ) |
| Policy contract number | 757730 |
| Policy instance | 11 |
| Insurance contract or identification number | 757730 | | Number of Individuals Covered | 310 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $1,477 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $20,705 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,189 | | Insurance broker organization code? | 3 |
|
| COMMUNITY EYE CARE (National Association of Insurance Commissioners NAIC id number: 52429 ) |
| Policy contract number | TP035012 |
| Policy instance | 10 |
| Insurance contract or identification number | TP035012 | | Number of Individuals Covered | 536 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-04-30 | | Total amount of commissions paid to insurance broker | USD $1,428 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $11,901 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,428 | | Insurance broker organization code? | 3 |
|
| COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 ) |
| Policy contract number | E4894531 |
| Policy instance | 9 |
| Insurance contract or identification number | E4894531 | | Number of Individuals Covered | 289 | | Insurance policy start date | 2019-05-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $32,446 | | Total amount of fees paid to insurance company | USD $3,665 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $115,671 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $10,721 | | Amount paid for insurance broker fees | 1844 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GVTL0BCBZ |
| Policy instance | 8 |
| Insurance contract or identification number | GVTL0BCBZ | | Number of Individuals Covered | 476 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $11,300 | | Total amount of fees paid to insurance company | USD $3,623 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $75,334 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $11,300 | | Amount paid for insurance broker fees | 1128 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUNJ0BCBZ |
| Policy instance | 7 |
| Insurance contract or identification number | GUNJ0BCBZ | | Number of Individuals Covered | 160 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $2,278 | | Total amount of fees paid to insurance company | USD $350 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $15,187 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,278 | | Amount paid for insurance broker fees | 350 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG0BCBZ |
| Policy instance | 5 |
| Insurance contract or identification number | GLUG0BCBZ | | Number of Individuals Covered | 941 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $3,202 | | Total amount of fees paid to insurance company | USD $2,616 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $21,346 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,202 | | Amount paid for insurance broker fees | 353 | | Insurance broker organization code? | 3 |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 0909070 |
| Policy instance | 4 |
| Insurance contract or identification number | 0909070 | | Number of Individuals Covered | 297 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $7,627 | | 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 | | Commission paid to Insurance Broker | USD $7,007 | | Insurance broker organization code? | 3 |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 02W4986 |
| Policy instance | 3 |
| Insurance contract or identification number | 02W4986 | | Number of Individuals Covered | 192 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $41,762 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,032,422 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $41,762 | | Insurance broker organization code? | 3 |
|
| BLUE CROSS BLUE SHIELD OF ALABAMA (National Association of Insurance Commissioners NAIC id number: 55433 ) |
| Policy contract number | 46181 |
| Policy instance | 2 |
| Insurance contract or identification number | 46181 | | Number of Individuals Covered | 366 | | 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 |
|
| COMPANION LIFE (National Association of Insurance Commissioners NAIC id number: 77828 ) |
| Policy contract number | CLI 96451 |
| Policy instance | 1 |
| Insurance contract or identification number | CLI 96451 | | Number of Individuals Covered | 222 | | 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 $7,478 | | Welfare Benefit Premiums Paid to Carrier | USD $249,253 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 7478 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUG 0BCBZ |
| Policy instance | 6 |
| Insurance contract or identification number | GUG 0BCBZ | | Number of Individuals Covered | 777 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $5,097 | | Total amount of fees paid to insurance company | USD $2,722 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $33,980 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,097 | | Amount paid for insurance broker fees | 557 | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 934271 |
| Policy instance | 4 |
| Insurance contract or identification number | 934271 | | Number of Individuals Covered | 154 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2019-01-01 | | Total amount of commissions paid to insurance broker | USD $4,504 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $14,961 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,286 | | Insurance broker organization code? | 3 |
|
| HCC LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 92711 ) |
| Policy contract number | HCL18413 |
| Policy instance | 1 |
| Insurance contract or identification number | HCL18413 | | Number of Individuals Covered | 227 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-04-30 | | 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 $118,696 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| COMPANION LIFE (National Association of Insurance Commissioners NAIC id number: 77828 ) |
| Policy contract number | CLI 96451 |
| Policy instance | 2 |
| Insurance contract or identification number | CLI 96451 | | Number of Individuals Covered | 232 | | Insurance policy start date | 2018-05-01 | | Insurance policy end date | 2018-12-31 | | 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 $178,484 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Insurance broker organization code? | 3 |
|
| BLUE CROSS BLUE SHIELD OF ALABAMA (National Association of Insurance Commissioners NAIC id number: 55433 ) |
| Policy contract number | 46181 |
| Policy instance | 3 |
| Insurance contract or identification number | 46181 | | Number of Individuals Covered | 357 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | 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 |
|
| COMMUNITY EYE CARE (National Association of Insurance Commissioners NAIC id number: 52429 ) |
| Policy contract number | TP035012 |
| Policy instance | 17 |
| Insurance contract or identification number | TP035012 | | Number of Individuals Covered | 529 | | Insurance policy start date | 2018-05-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $2,726 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $22,719 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,726 | | Insurance broker organization code? | 3 |
|
| COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 ) |
| Policy contract number | E4894531 |
| Policy instance | 16 |
| Insurance contract or identification number | E4894531 | | Number of Individuals Covered | 268 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $37,754 | | Total amount of fees paid to insurance company | USD $17,462 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $69,436 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $11,480 | | Amount paid for insurance broker fees | 11705 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000BCBZ |
| Policy instance | 15 |
| Insurance contract or identification number | G000BCBZ | | Number of Individuals Covered | 239 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2019-01-01 | | Total amount of commissions paid to insurance broker | USD $7,541 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $50,275 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,541 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000BCBZ |
| Policy instance | 14 |
| Insurance contract or identification number | G000BCBZ | | Number of Individuals Covered | 0 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2019-01-01 | | Total amount of commissions paid to insurance broker | USD $7,085 | | Total amount of fees paid to insurance company | USD $0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,085 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000BCBZ |
| Policy instance | 13 |
| Insurance contract or identification number | G000BCBZ | | Number of Individuals Covered | 76 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2019-01-01 | | Total amount of commissions paid to insurance broker | USD $1,499 | | Total amount of fees paid to insurance company | USD $0 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $9,991 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,499 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000BCBZ |
| Policy instance | 12 |
| Insurance contract or identification number | G000BCBZ | | Number of Individuals Covered | 380 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2019-01-01 | | Total amount of commissions paid to insurance broker | USD $3,337 | | Total amount of fees paid to insurance company | USD $0 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $22,245 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,337 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000BCBZ |
| Policy instance | 11 |
| Insurance contract or identification number | G000BCBZ | | Number of Individuals Covered | 458 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2019-01-01 | | Total amount of commissions paid to insurance broker | USD $2,098 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $13,988 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,098 | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | R0585877 |
| Policy instance | 10 |
| Insurance contract or identification number | R0585877 | | Number of Individuals Covered | 340 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2019-01-01 | | Total amount of commissions paid to insurance broker | USD $1,183 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | GCIEE, GRPACCVO, GRPHSPVO | | Welfare Benefit Premiums Paid to Carrier | USD $16,965 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,183 | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 396319 |
| Policy instance | 9 |
| Insurance contract or identification number | 396319 | | Number of Individuals Covered | 92 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2019-01-01 | | Total amount of commissions paid to insurance broker | USD $5,595 | | Total amount of fees paid to insurance company | USD $0 | | Temporary Disability Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,595 | | Insurance broker organization code? | 3 |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 0909070 |
| Policy instance | 8 |
| Insurance contract or identification number | 0909070 | | Number of Individuals Covered | 170 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $9,173 | | 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 | | Commission paid to Insurance Broker | USD $9,173 | | Insurance broker organization code? | 7 |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 02W4986 |
| Policy instance | 7 |
| Insurance contract or identification number | 02W4986 | | Number of Individuals Covered | 197 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $33,202 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $781,893 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $29,675 | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 934273 |
| Policy instance | 6 |
| Insurance contract or identification number | 934273 | | Number of Individuals Covered | 165 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2019-01-01 | | Total amount of commissions paid to insurance broker | USD $4,569 | | Total amount of fees paid to insurance company | USD $0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $20,113 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,352 | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 934272 |
| Policy instance | 5 |
| Insurance contract or identification number | 934272 | | Number of Individuals Covered | 461 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2019-01-01 | | Total amount of commissions paid to insurance broker | USD $4,612 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $19,624 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,363 | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 396319 |
| Policy instance | 10 |
| Insurance contract or identification number | 396319 | | Number of Individuals Covered | 91 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2018-01-01 | | Total amount of commissions paid to insurance broker | USD $2,051 | | Total amount of fees paid to insurance company | USD $0 | | Temporary Disability Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,051 | | Insurance broker organization code? | 3 | | Insurance broker name | USI INSURANCE SERVICES LLC |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 0909070 |
| Policy instance | 9 |
| Insurance contract or identification number | 0909070 | | Number of Individuals Covered | 501 | | Insurance policy start date | 2017-06-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $4,899 | | 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 | | Commission paid to Insurance Broker | USD $4,899 | | Insurance broker organization code? | 3 | | Insurance broker name | USI INSURANCE SERVICES LLC |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 02W4986 |
| Policy instance | 8 |
| Insurance contract or identification number | 02W4986 | | Number of Individuals Covered | 71 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $10,945 | | 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 | | Commission paid to Insurance Broker | USD $10,945 | | Insurance broker organization code? | 3 | | Insurance broker name | USI INSURANCE SERVICES LLC |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 934273 |
| Policy instance | 7 |
| Insurance contract or identification number | 934273 | | Number of Individuals Covered | 157 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2018-01-01 | | Total amount of commissions paid to insurance broker | USD $7,913 | | Total amount of fees paid to insurance company | USD $0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $54,993 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,913 | | Insurance broker organization code? | 3 | | Insurance broker name | USI INSURANCE SERVICES LLC |
|
| HCC LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 92711 ) |
| Policy contract number | HCL18413 |
| Policy instance | 1 |
| Insurance contract or identification number | HCL18413 | | Number of Individuals Covered | 232 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-04-30 | | 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 $92,182 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Insurance broker name | USI INSURANCE SERVICES LLC |
|
| HCC LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 92711 ) |
| Policy contract number | HCL18413 |
| Policy instance | 2 |
| Insurance contract or identification number | HCL18413 | | Insurance policy start date | 2017-05-01 | | 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 | | Welfare Benefit Premiums Paid to Carrier | USD $205,797 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Insurance broker organization code? | 3 | | Insurance broker name | JH BERRY RISK SERVICES, LLC |
|
| BLUE CROSS BLUE SHIELD OF ALABAMA (National Association of Insurance Commissioners NAIC id number: 55433 ) |
| Policy contract number | 46181 |
| Policy instance | 3 |
| Insurance contract or identification number | 46181 | | Number of Individuals Covered | 503 | | 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 |
|
| COMPBENEFITS (National Association of Insurance Commissioners NAIC id number: 60984 ) |
| Policy contract number | VS1665 |
| Policy instance | 4 |
| Insurance contract or identification number | VS1665 | | Number of Individuals Covered | 152 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-05-31 | | Total amount of commissions paid to insurance broker | USD $943 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $9,426 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $943 | | Insurance broker organization code? | 3 | | Insurance broker name | USI INSURANCE SERVICES LLC |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 934271 |
| Policy instance | 5 |
| Insurance contract or identification number | 934271 | | Number of Individuals Covered | 154 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2018-01-01 | | Total amount of commissions paid to insurance broker | USD $8,457 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $44,235 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,457 | | Insurance broker organization code? | 3 | | Insurance broker name | USI INSURANCE SERVICES LLC |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 934272 |
| Policy instance | 6 |
| Insurance contract or identification number | 934272 | | Number of Individuals Covered | 415 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2018-01-01 | | Total amount of commissions paid to insurance broker | USD $7,832 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $54,902 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,832 | | Insurance broker organization code? | 3 | | Insurance broker name | USI INSURANCE SERVICES LLC |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | R0585877 |
| Policy instance | 8 |
| Insurance contract or identification number | R0585877 | | Number of Individuals Covered | 310 | | Insurance policy start date | 2015-05-01 | | Insurance policy end date | 2016-04-30 | | Total amount of commissions paid to insurance broker | USD $16,832 | | Are there contracts with allocated funds for individual policies? | No | | 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 | SUPPLEMENTAL LIFE, GROUP ACCIDENT, GROUP 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 $55,740 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| COMPBENEFITS (National Association of Insurance Commissioners NAIC id number: 60984 ) |
| Policy contract number | VS1665 |
| Policy instance | 7 |
| Insurance contract or identification number | VS1665 | | Number of Individuals Covered | 115 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $828 | | Are there contracts with allocated funds for individual policies? | No | | 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 $17,621 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| BLUECROSS BLUESHIELD OF TENNESSEE, INC. (National Association of Insurance Commissioners NAIC id number: 54518 ) |
| Policy contract number | 129828 |
| Policy instance | 6 |
| Insurance contract or identification number | 129828 | | Number of Individuals Covered | 46 | | Insurance policy start date | 2015-05-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $6,024 | | Are there contracts with allocated funds for individual policies? | No | | 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 $76,718 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| BLUE CROSS BLUE SHIELD OF MS, INC. (National Association of Insurance Commissioners NAIC id number: 60111 ) |
| Policy contract number | 47521 ET AL |
| Policy instance | 5 |
| Insurance contract or identification number | 47521 ET AL | | Number of Individuals Covered | 7 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $2,447 | | Are there contracts with allocated funds for individual policies? | No | | 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 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| BLUE CROSS BLUE SHIELD OF ALABAMA (National Association of Insurance Commissioners NAIC id number: 55433 ) |
| Policy contract number | 46181 |
| Policy instance | 4 |
| Insurance contract or identification number | 46181 | | Number of Individuals Covered | 455 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | 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 | | 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 | GUPR0310A |
| Policy instance | 3 |
| Insurance contract or identification number | GUPR0310A | | Number of Individuals Covered | 78 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-05-01 | | Total amount of commissions paid to insurance broker | USD $1,493 | | Are there contracts with allocated funds for individual policies? | No | | 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 $9,951 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HCC LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 92711 ) |
| Policy contract number | HCL18413 |
| Policy instance | 2 |
| Insurance contract or identification number | HCL18413 | | Number of Individuals Covered | 211 | | Insurance policy start date | 2015-05-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $37,050 | | Are there contracts with allocated funds for individual policies? | No | | 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 | | 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 $163,628 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HCC LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 92711 ) |
| Policy contract number | HCL18413 |
| Policy instance | 1 |
| Insurance contract or identification number | HCL18413 | | Number of Individuals Covered | 181 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-04-30 | | Are there contracts with allocated funds for individual policies? | No | | 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 | | 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 $66,018 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| AMERICAN UNITED LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60895 ) |
| Policy contract number | G00611838 |
| Policy instance | 1 |
| Insurance contract or identification number | G00611838 | | Number of Individuals Covered | 294 | | Insurance policy start date | 2014-02-01 | | Insurance policy end date | 2015-02-28 | | Total amount of commissions paid to insurance broker | USD $6,643 | | Are there contracts with allocated funds for individual policies? | No | | 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 | 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 $44,289 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $502 | | Insurance broker organization code? | 3 | | Insurance broker name | USI INSURANCE SERVICES LLC |
|
| AMERICAN UNITED LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60895 ) |
| Policy contract number | G00611838 |
| Policy instance | 6 |
| Insurance contract or identification number | G00611838 | | Number of Individuals Covered | 33 | | Insurance policy start date | 2014-02-01 | | Insurance policy end date | 2015-02-28 | | Total amount of commissions paid to insurance broker | USD $2,809 | | Are there contracts with allocated funds for individual policies? | No | | 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 | | 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 $18,727 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $212 | | Insurance broker organization code? | 3 | | Insurance broker name | USI INSURANCE SERVICES LLC |
|
| HCC LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 92711 ) |
| Policy contract number | HCL18413 |
| Policy instance | 5 |
| Insurance contract or identification number | HCL18413 | | Number of Individuals Covered | 187 | | Insurance policy start date | 2014-05-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $53,081 | | Are there contracts with allocated funds for individual policies? | No | | 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 | | 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 $142,847 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $53,081 | | Insurance broker organization code? | 3 | | Insurance broker name | USI INSURANCE SERVICES LLC |
|
| BLUE CROSS BLUE SHIELD OF MS, INC. (National Association of Insurance Commissioners NAIC id number: 60111 ) |
| Policy contract number | 47521 & 47522 |
| Policy instance | 3 |
| Insurance contract or identification number | 47521 & 47522 | | Number of Individuals Covered | 7 | | Insurance policy start date | 2014-05-01 | | Insurance policy end date | 2015-04-30 | | Total amount of commissions paid to insurance broker | USD $3,452 | | Are there contracts with allocated funds for individual policies? | No | | 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 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,452 | | Insurance broker organization code? | 3 | | Insurance broker name | SAMMY SMITH & ASSOC. INC. |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUPR0310A |
| Policy instance | 4 |
| Insurance contract or identification number | GUPR0310A | | Number of Individuals Covered | 78 | | Insurance policy start date | 2014-05-01 | | Insurance policy end date | 2015-05-01 | | Total amount of commissions paid to insurance broker | USD $4,368 | | Are there contracts with allocated funds for individual policies? | No | | 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 $29,123 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,368 | | Insurance broker organization code? | 3 | | Insurance broker name | USI INSURANCE SERVICES LLC |
|
| HCC LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 92711 ) |
| Policy contract number | HCL18413 |
| Policy instance | 1 |
| Insurance contract or identification number | HCL18413 | | Number of Individuals Covered | 133 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-04-30 | | Are there contracts with allocated funds for individual policies? | No | | 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 | | 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 $52,727 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| AMERICAN UNITED LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60895 ) |
| Policy contract number | G00611838 |
| Policy instance | 9 |
| Insurance contract or identification number | G00611838 | | Number of Individuals Covered | 294 | | Insurance policy start date | 2014-02-01 | | Insurance policy end date | 2015-02-28 | | Total amount of commissions paid to insurance broker | USD $6,643 | | Are there contracts with allocated funds for individual policies? | No | | 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 | 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 $44,289 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| AMERICAN UNITED LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60895 ) |
| Policy contract number | G00611838 |
| Policy instance | 8 |
| Insurance contract or identification number | G00611838 | | Number of Individuals Covered | 33 | | Insurance policy start date | 2014-02-01 | | Insurance policy end date | 2015-02-28 | | Total amount of commissions paid to insurance broker | USD $2,809 | | Are there contracts with allocated funds for individual policies? | No | | 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 | | 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 $18,727 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 396319 |
| Policy instance | 7 |
| Insurance contract or identification number | 396319 | | Number of Individuals Covered | 68 | | Insurance policy start date | 2014-05-01 | | Insurance policy end date | 2015-05-01 | | Total amount of commissions paid to insurance broker | USD $875 | | Total amount of fees paid to insurance company | USD $44 | | Are there contracts with allocated funds for individual policies? | No | | 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 | | 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 $17,739 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $875 | | Amount paid for insurance broker fees | 44 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | MOLTON, ALLEN & WILLIAMS, LLC |
|
| COMPBENEFITS (National Association of Insurance Commissioners NAIC id number: 60984 ) |
| Policy contract number | VS1665 |
| Policy instance | 6 |
| Insurance contract or identification number | VS1665 | | Number of Individuals Covered | 81 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $1,434 | | Are there contracts with allocated funds for individual policies? | No | | 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 $14,328 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| BLUE CROSS BLUE SHIELD OF MS, INC. (National Association of Insurance Commissioners NAIC id number: 60111 ) |
| Policy contract number | 47521 & 47522 |
| Policy instance | 5 |
| Insurance contract or identification number | 47521 & 47522 | | Number of Individuals Covered | 7 | | Insurance policy start date | 2014-05-01 | | Insurance policy end date | 2015-04-30 | | Total amount of commissions paid to insurance broker | USD $3,452 | | Are there contracts with allocated funds for individual policies? | No | | 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 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| BLUE CROSS BLUE SHIELD OF ALABAMA (National Association of Insurance Commissioners NAIC id number: 55433 ) |
| Policy contract number | 46181 |
| Policy instance | 4 |
| Insurance contract or identification number | 46181 | | Number of Individuals Covered | 368 | | Insurance policy start date | 2014-05-01 | | Insurance policy end date | 2015-04-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | 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 | | 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 | GUPR0310A |
| Policy instance | 3 |
| Insurance contract or identification number | GUPR0310A | | Number of Individuals Covered | 78 | | Insurance policy start date | 2014-05-01 | | Insurance policy end date | 2015-05-01 | | Total amount of commissions paid to insurance broker | USD $4,368 | | Are there contracts with allocated funds for individual policies? | No | | 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 $29,123 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HCC LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 92711 ) |
| Policy contract number | HCL18413 |
| Policy instance | 2 |
| Insurance contract or identification number | HCL18413 | | Number of Individuals Covered | 187 | | Insurance policy start date | 2014-05-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $53,081 | | Are there contracts with allocated funds for individual policies? | No | | 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 | | 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 $142,847 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HCC LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 92711 ) |
| Policy contract number | HCL18413 |
| Policy instance | 8 |
| Insurance contract or identification number | HCL18413 | | Number of Individuals Covered | 133 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-04-30 | | Are there contracts with allocated funds for individual policies? | No | | 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 | | 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 $52,727 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| COMPBENEFITS (National Association of Insurance Commissioners NAIC id number: 60984 ) |
| Policy contract number | VS1665 |
| Policy instance | 9 |
| Insurance contract or identification number | VS1665 | | Number of Individuals Covered | 81 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $1,434 | | Are there contracts with allocated funds for individual policies? | No | | 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 $14,328 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $34 | | Insurance broker organization code? | 3 | | Insurance broker name | USI INSURANCE SERVICES LLC |
|
| BLUE CROSS BLUE SHIELD OF ALABAMA (National Association of Insurance Commissioners NAIC id number: 55433 ) |
| Policy contract number | 46181 |
| Policy instance | 2 |
| Insurance contract or identification number | 46181 | | Number of Individuals Covered | 368 | | Insurance policy start date | 2014-05-01 | | Insurance policy end date | 2015-04-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | 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 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| AMERICAN UNITED LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60895 ) |
| Policy contract number | G00611838 |
| Policy instance | 1 |
| Insurance contract or identification number | G00611838 | | Number of Individuals Covered | 36 | | Insurance policy start date | 2013-02-01 | | Insurance policy end date | 2014-01-31 | | Total amount of commissions paid to insurance broker | USD $2,466 | | Are there contracts with allocated funds for individual policies? | No | | 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 | | 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 $16,439 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,466 | | Insurance broker organization code? | 3 | | Insurance broker name | MOLTON, ALLEN & WILLIAMS, LLC |
|
| BLUE CROSS BLUE SHIELD OF ALABAMA (National Association of Insurance Commissioners NAIC id number: 55433 ) |
| Policy contract number | 46181 |
| Policy instance | 2 |
| Insurance contract or identification number | 46181 | | Number of Individuals Covered | 356 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Are there contracts with allocated funds for individual policies? | No | | 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 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| AMERICAN UNITED LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60895 ) |
| Policy contract number | G00611838 |
| Policy instance | 7 |
| Insurance contract or identification number | G00611838 | | Number of Individuals Covered | 36 | | Insurance policy start date | 2013-02-01 | | Insurance policy end date | 2014-01-31 | | Total amount of commissions paid to insurance broker | USD $2,466 | | Are there contracts with allocated funds for individual policies? | No | | 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 | | 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 $16,439 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| COMPBENEFITS (National Association of Insurance Commissioners NAIC id number: 60984 ) |
| Policy contract number | VS1665 |
| Policy instance | 4 |
| Insurance contract or identification number | VS1665 | | Number of Individuals Covered | 76 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $1,508 | | Are there contracts with allocated funds for individual policies? | No | | 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 $12,739 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,508 | | Insurance broker organization code? | 3 | | Insurance broker name | MOLTON, ALLEN & WILLIAMS, LLC |
|
| AMERICAN UNITED LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60895 ) |
| Policy contract number | G00611838 |
| Policy instance | 5 |
| Insurance contract or identification number | G00611838 | | Number of Individuals Covered | 301 | | Insurance policy start date | 2013-02-01 | | Insurance policy end date | 2014-01-31 | | Total amount of commissions paid to insurance broker | USD $6,381 | | Are there contracts with allocated funds for individual policies? | No | | 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 | 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 $42,537 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,381 | | Insurance broker organization code? | 3 | | Insurance broker name | MOLTON, ALLEN & WILLIAMS, LLC |
|
| PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 ) |
| Policy contract number | 53736 |
| Policy instance | 6 |
| Insurance contract or identification number | 53736 | | Number of Individuals Covered | 64 | | Insurance policy start date | 2013-02-01 | | Insurance policy end date | 2013-04-30 | | Total amount of commissions paid to insurance broker | USD $1,053 | | Are there contracts with allocated funds for individual policies? | No | | 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 | | 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 $7,017 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| COMPBENEFITS (National Association of Insurance Commissioners NAIC id number: 60984 ) |
| Policy contract number | VS1665 |
| Policy instance | 5 |
| Insurance contract or identification number | VS1665 | | Number of Individuals Covered | 76 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $1,508 | | Are there contracts with allocated funds for individual policies? | No | | 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 $12,739 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| BLUE CROSS BLUE SHIELD OF MS, INC. (National Association of Insurance Commissioners NAIC id number: 60111 ) |
| Policy contract number | 47521 47522 |
| Policy instance | 4 |
| Insurance contract or identification number | 47521 47522 | | Number of Individuals Covered | 29 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $3,622 | | Total amount of fees paid to insurance company | USD $874 | | Are there contracts with allocated funds for individual policies? | No | | 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 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HCC LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 92711 ) |
| Policy contract number | HCL18413 |
| Policy instance | 7 |
| Insurance contract or identification number | HCL18413 | | Number of Individuals Covered | 133 | | Insurance policy start date | 2013-05-01 | | Insurance policy end date | 2014-04-30 | | Total amount of commissions paid to insurance broker | USD $20,789 | | Are there contracts with allocated funds for individual policies? | No | | 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 | | 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 $152,375 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $20,789 | | Insurance broker organization code? | 3 | | Insurance broker name | MOLTON, ALLEN & WILLIAMS, LLC |
|
| BLUE CROSS BLUE SHIELD OF ALABAMA (National Association of Insurance Commissioners NAIC id number: 55433 ) |
| Policy contract number | 46181 |
| Policy instance | 3 |
| Insurance contract or identification number | 46181 | | Number of Individuals Covered | 356 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Are there contracts with allocated funds for individual policies? | No | | 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 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HCC LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 92711 ) |
| Policy contract number | HCL18413 |
| Policy instance | 1 |
| Insurance contract or identification number | HCL18413 | | Number of Individuals Covered | 133 | | Insurance policy start date | 2013-05-01 | | Insurance policy end date | 2014-04-30 | | Total amount of commissions paid to insurance broker | USD $20,789 | | Are there contracts with allocated funds for individual policies? | No | | 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 | | 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 $152,375 | | 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 | GUPR0310A |
| Policy instance | 2 |
| Insurance contract or identification number | GUPR0310A | | Number of Individuals Covered | 82 | | Insurance policy start date | 2013-05-01 | | Insurance policy end date | 2014-05-01 | | Total amount of commissions paid to insurance broker | USD $4,416 | | Total amount of fees paid to insurance company | USD $610 | | Are there contracts with allocated funds for individual policies? | No | | 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 $29,436 | | 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 | GUPR0310A |
| Policy instance | 3 |
| Insurance contract or identification number | GUPR0310A | | Number of Individuals Covered | 82 | | Insurance policy start date | 2013-05-01 | | Insurance policy end date | 2014-05-01 | | Total amount of commissions paid to insurance broker | USD $4,416 | | Total amount of fees paid to insurance company | USD $610 | | Are there contracts with allocated funds for individual policies? | No | | 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 $29,436 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,850 | | Amount paid for insurance broker fees | 610 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | MOLTON, ALLEN & WILLIAMS, LLC |
|
| BLUE CROSS BLUE SHIELD OF MS, INC. (National Association of Insurance Commissioners NAIC id number: 60111 ) |
| Policy contract number | 47521 47522 |
| Policy instance | 6 |
| Insurance contract or identification number | 47521 47522 | | Number of Individuals Covered | 29 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $3,622 | | Total amount of fees paid to insurance company | USD $874 | | Are there contracts with allocated funds for individual policies? | No | | 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 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,622 | | Amount paid for insurance broker fees | 874 | | Additional information about fees paid to insurance broker | OTHER FEES | | Insurance broker organization code? | 3 | | Insurance broker name | SAMMY SMITH & ASSOCIATES, INC. |
|
| PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 ) |
| Policy contract number | 53736 |
| Policy instance | 8 |
| Insurance contract or identification number | 53736 | | Number of Individuals Covered | 64 | | Insurance policy start date | 2013-02-01 | | Insurance policy end date | 2013-04-30 | | Total amount of commissions paid to insurance broker | USD $1,053 | | Are there contracts with allocated funds for individual policies? | No | | 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 | | 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 $7,017 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,053 | | Insurance broker organization code? | 3 | | Insurance broker name | MOLTON, ALLEN & WILLIAMS, LLC |
|
| AMERICAN UNITED LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60895 ) |
| Policy contract number | G00611838 |
| Policy instance | 8 |
| Insurance contract or identification number | G00611838 | | Number of Individuals Covered | 301 | | Insurance policy start date | 2013-02-01 | | Insurance policy end date | 2014-01-31 | | Total amount of commissions paid to insurance broker | USD $6,381 | | Are there contracts with allocated funds for individual policies? | No | | 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 | 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 $42,537 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HCC LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 92711 ) |
| Policy contract number | HCL18413 |
| Policy instance | 1 |
| Insurance contract or identification number | HCL18413 | | Number of Individuals Covered | 125 | | Insurance policy start date | 2012-05-01 | | Insurance policy end date | 2013-04-30 | | Total amount of commissions paid to insurance broker | USD $19,866 | | Welfare Benefit Premiums Paid to Carrier | USD $145,618 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $19,866 | | Insurance broker organization code? | 3 | | Insurance broker name | MOLTON ALLEN & WILLIAMS LLC |
|
| AMERICAN UNITED LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60895 ) |
| Policy contract number | G00611838 |
| Policy instance | 8 |
| Insurance contract or identification number | G00611838 | | Number of Individuals Covered | 42 | | Insurance policy start date | 2012-02-01 | | Insurance policy end date | 2013-01-31 | | Total amount of commissions paid to insurance broker | USD $1,446 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $9,639 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,446 | | Insurance broker organization code? | 3 | | Insurance broker name | MOLTON ALLEN & WILLIAMS LLC |
|
| PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 ) |
| Policy contract number | 53736 |
| Policy instance | 7 |
| Insurance contract or identification number | 53736 | | Number of Individuals Covered | 194 | | Insurance policy start date | 2012-02-01 | | Insurance policy end date | 2012-03-31 | | Total amount of commissions paid to insurance broker | USD $3,818 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $25,816 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,818 | | Insurance broker organization code? | 3 | | Insurance broker name | MOLTON ALLEN & WILLIAMS LLC |
|
| PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 ) |
| Policy contract number | 53736 |
| Policy instance | 6 |
| Insurance contract or identification number | 53736 | | Number of Individuals Covered | 7 | | Insurance policy start date | 2012-02-01 | | Insurance policy end date | 2012-03-31 | | Total amount of commissions paid to insurance broker | USD $159 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $696 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $159 | | Insurance broker organization code? | 3 | | Insurance broker name | MOLTON ALLEN & WILLIAMS LLC |
|
| COMPBENEFITS (National Association of Insurance Commissioners NAIC id number: 60984 ) |
| Policy contract number | VS1665 |
| Policy instance | 5 |
| Insurance contract or identification number | VS1665 | | Number of Individuals Covered | 82 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $1,295 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $15,263 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,295 | | Insurance broker organization code? | 3 | | Insurance broker name | MOLTON ALLEN & WILLIAMS LLC |
|
| BLUE CROSS BLUE SHIELD OF MS, INC. (National Association of Insurance Commissioners NAIC id number: 60111 ) |
| Policy contract number | 47521 47522 |
| Policy instance | 4 |
| Insurance contract or identification number | 47521 47522 | | Number of Individuals Covered | 26 | | Insurance policy start date | 2011-10-01 | | Insurance policy end date | 2012-09-30 | | Total amount of commissions paid to insurance broker | USD $3,258 | | 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 | | Commission paid to Insurance Broker | USD $3,258 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | SAMMY SMITH & ASSOCIATES INC |
|
| BLUE CROSS BLUE SHIELD OF ALABAMA (National Association of Insurance Commissioners NAIC id number: 55433 ) |
| Policy contract number | 46181 |
| Policy instance | 3 |
| Insurance contract or identification number | 46181 | | Number of Individuals Covered | 354 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | 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 | GUPR0310A |
| Policy instance | 2 |
| Insurance contract or identification number | GUPR0310A | | Number of Individuals Covered | 90 | | Insurance policy start date | 2012-05-01 | | Insurance policy end date | 2013-05-01 | | Total amount of commissions paid to insurance broker | USD $4,486 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $29,908 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,486 | | Insurance broker organization code? | 3 | | Insurance broker name | MOLTON ALLEN & WILLIAMS LLC |
|
| AMERICAN UNITED LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60895 ) |
| Policy contract number | G00611838 |
| Policy instance | 9 |
| Insurance contract or identification number | G00611838 | | Number of Individuals Covered | 275 | | Insurance policy start date | 2012-02-01 | | Insurance policy end date | 2013-01-31 | | Total amount of commissions paid to insurance broker | USD $5,766 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $38,442 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,766 | | Insurance broker organization code? | 3 | | Insurance broker name | MOLTON ALLEN & WILLIAMS LLC |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUPR0310A |
| Policy instance | 2 |
| Insurance contract or identification number | GUPR0310A | | Number of Individuals Covered | 99 | | Insurance policy start date | 2011-05-01 | | Insurance policy end date | 2012-05-01 | | Total amount of commissions paid to insurance broker | USD $4,404 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $29,357 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| BLUE CROSS BLUE SHIELD OF MS, INC. (National Association of Insurance Commissioners NAIC id number: 60111 ) |
| Policy contract number | 47521 |
| Policy instance | 4 |
| Insurance contract or identification number | 47521 | | Number of Individuals Covered | 16 | | Insurance policy start date | 2010-10-01 | | Insurance policy end date | 2011-09-30 | | Total amount of commissions paid to insurance broker | USD $1,845 | | Total amount of fees paid to insurance company | USD $922 | | Health Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 ) |
| Policy contract number | 53736 |
| Policy instance | 6 |
| Insurance contract or identification number | 53736 | | Number of Individuals Covered | 7 | | Insurance policy start date | 2011-02-01 | | Insurance policy end date | 2012-01-31 | | Total amount of commissions paid to insurance broker | USD $221 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $4,209 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 ) |
| Policy contract number | 53736 |
| Policy instance | 7 |
| Insurance contract or identification number | 53736 | | Number of Individuals Covered | 194 | | Insurance policy start date | 2011-02-01 | | Insurance policy end date | 2012-01-31 | | Total amount of commissions paid to insurance broker | USD $5,308 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $32,651 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| COMPBENEFITS (National Association of Insurance Commissioners NAIC id number: 60984 ) |
| Policy contract number | VS1665 |
| Policy instance | 5 |
| Insurance contract or identification number | VS1665 | | Number of Individuals Covered | 79 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2011-12-31 | | Total amount of commissions paid to insurance broker | USD $1,530 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $12,923 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HCC LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 92711 ) |
| Policy contract number | HCL18413 |
| Policy instance | 1 |
| Insurance contract or identification number | HCL18413 | | Number of Individuals Covered | 128 | | Insurance policy start date | 2011-05-01 | | Insurance policy end date | 2012-04-30 | | Total amount of commissions paid to insurance broker | USD $20,306 | | Welfare Benefit Premiums Paid to Carrier | USD $148,823 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| BLUE CROSS BLUE SHIELD OF ALABAMA (National Association of Insurance Commissioners NAIC id number: 55433 ) |
| Policy contract number | 46181 |
| Policy instance | 3 |
| Insurance contract or identification number | 46181 | | Number of Individuals Covered | 344 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2011-12-31 | | Total amount of commissions paid to insurance broker | 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 |
|
| AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 ) |
| Policy contract number | AFA0074 |
| Policy instance | 1 |
| Insurance contract or identification number | AFA0074 | | Number of Individuals Covered | 149 | | Insurance policy start date | 2010-05-01 | | Insurance policy end date | 2011-04-30 | | Total amount of commissions paid to insurance broker | USD $19,605 | | Welfare Benefit Premiums Paid to Carrier | USD $143,843 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $19,605 | | Insurance broker organization code? | 3 | | Insurance broker name | MOLTON, ALLEN & WILLIAMS, LLC |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUPR0310A |
| Policy instance | 2 |
| Insurance contract or identification number | GUPR0310A | | Number of Individuals Covered | 114 | | Insurance policy start date | 2010-05-01 | | Insurance policy end date | 2011-05-01 | | Total amount of commissions paid to insurance broker | USD $4,239 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $28,259 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,239 | | Insurance broker organization code? | 3 | | Insurance broker name | MOLTON, ALLEN, & WILLIAMS, LLC |
|
| BLUE CROSS BLUE SHIELD OF ALABAMA (National Association of Insurance Commissioners NAIC id number: 55433 ) |
| Policy contract number | 46181 |
| Policy instance | 3 |
| Insurance contract or identification number | 46181 | | Number of Individuals Covered | 328 | | Insurance policy start date | 2010-01-01 | | Insurance policy end date | 2010-12-31 | | Total amount of commissions paid to insurance broker | 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 |
|
| COMPBENEFITS (National Association of Insurance Commissioners NAIC id number: 60984 ) |
| Policy contract number | VS1665 |
| Policy instance | 5 |
| Insurance contract or identification number | VS1665 | | Number of Individuals Covered | 81 | | Insurance policy start date | 2010-01-01 | | Insurance policy end date | 2010-12-31 | | Total amount of commissions paid to insurance broker | USD $1,395 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $16,291 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,395 | | Insurance broker organization code? | 3 | | Insurance broker name | MOLTON, ALLEN, & WILLIAMS, LLC |
|
| BLUE CROSS BLUE SHIELD OF MS, INC. (National Association of Insurance Commissioners NAIC id number: 60111 ) |
| Policy contract number | 47521 |
| Policy instance | 4 |
| Insurance contract or identification number | 47521 | | Insurance policy start date | 2009-10-01 | | Insurance policy end date | 2010-09-30 | | Total amount of commissions paid to insurance broker | USD $3,564 | | Total amount of fees paid to insurance company | USD $1,482 | | Health Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,564 | | Amount paid for insurance broker fees | 1482 | | Insurance broker organization code? | 3 | | Insurance broker name | SAMMY SMITH & ASSOC INC |
|
| PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 ) |
| Policy contract number | 53736 |
| Policy instance | 7 |
| Insurance contract or identification number | 53736 | | Number of Individuals Covered | 186 | | Insurance policy start date | 2010-02-01 | | Insurance policy end date | 2011-01-31 | | Total amount of commissions paid to insurance broker | USD $4,998 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability 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 $4,998 | | Insurance broker organization code? | 3 | | Insurance broker name | MOLTON, ALLEN, & WILLIAMS, LLC |
|
| PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 ) |
| Policy contract number | 53736 |
| Policy instance | 6 |
| Insurance contract or identification number | 53736 | | Number of Individuals Covered | 8 | | Insurance policy start date | 2010-02-01 | | Insurance policy end date | 2011-01-31 | | Total amount of commissions paid to insurance broker | USD $208 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $4,955 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $208 | | Insurance broker organization code? | 3 | | Insurance broker name | MOLTON, ALLEN, & WILLIAMS, LLC |
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