ARKANSAS UROLOGY, P.A. has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan ARKANSAS UROLOGY, P.A. MEDICAL BENEFIT PLAN
401k plan membership statisitcs for ARKANSAS UROLOGY, P.A. MEDICAL BENEFIT PLAN
| Measure | Date | Value |
|---|
| 2021: ARKANSAS UROLOGY, P.A. MEDICAL BENEFIT PLAN 2021 401k membership |
|---|
| Total participants, beginning-of-year | 2021-07-01 | 432 |
| Total number of active participants reported on line 7a of the Form 5500 | 2021-07-01 | 432 |
| Number of retired or separated participants receiving benefits | 2021-07-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2021-07-01 | 0 |
| Total of all active and inactive participants | 2021-07-01 | 432 |
| 2020: ARKANSAS UROLOGY, P.A. MEDICAL BENEFIT PLAN 2020 401k membership |
|---|
| Total participants, beginning-of-year | 2020-07-01 | 265 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-07-01 | 356 |
| Number of retired or separated participants receiving benefits | 2020-07-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2020-07-01 | 0 |
| Total of all active and inactive participants | 2020-07-01 | 356 |
| 2019: ARKANSAS UROLOGY, P.A. MEDICAL BENEFIT PLAN 2019 401k membership |
|---|
| Total participants, beginning-of-year | 2019-07-01 | 265 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-07-01 | 265 |
| Number of retired or separated participants receiving benefits | 2019-07-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2019-07-01 | 0 |
| Total of all active and inactive participants | 2019-07-01 | 265 |
| 2018: ARKANSAS UROLOGY, P.A. MEDICAL BENEFIT PLAN 2018 401k membership |
|---|
| Total participants, beginning-of-year | 2018-07-01 | 242 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-07-01 | 265 |
| Number of retired or separated participants receiving benefits | 2018-07-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2018-07-01 | 0 |
| Total of all active and inactive participants | 2018-07-01 | 265 |
| 2017: ARKANSAS UROLOGY, P.A. MEDICAL BENEFIT PLAN 2017 401k membership |
|---|
| Total participants, beginning-of-year | 2017-07-01 | 222 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-07-01 | 242 |
| Number of retired or separated participants receiving benefits | 2017-07-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2017-07-01 | 0 |
| Total of all active and inactive participants | 2017-07-01 | 242 |
| 2016: ARKANSAS UROLOGY, P.A. MEDICAL BENEFIT PLAN 2016 401k membership |
|---|
| Total participants, beginning-of-year | 2016-07-01 | 207 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-07-01 | 222 |
| Number of retired or separated participants receiving benefits | 2016-07-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2016-07-01 | 0 |
| Total of all active and inactive participants | 2016-07-01 | 222 |
| 2015: ARKANSAS UROLOGY, P.A. MEDICAL BENEFIT PLAN 2015 401k membership |
|---|
| Total participants, beginning-of-year | 2015-07-01 | 230 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-07-01 | 207 |
| Number of retired or separated participants receiving benefits | 2015-07-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2015-07-01 | 0 |
| Total of all active and inactive participants | 2015-07-01 | 207 |
| 2014: ARKANSAS UROLOGY, P.A. MEDICAL BENEFIT PLAN 2014 401k membership |
|---|
| Total participants, beginning-of-year | 2014-07-01 | 221 |
| Total number of active participants reported on line 7a of the Form 5500 | 2014-07-01 | 230 |
| Number of retired or separated participants receiving benefits | 2014-07-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2014-07-01 | 0 |
| Total of all active and inactive participants | 2014-07-01 | 230 |
| 2013: ARKANSAS UROLOGY, P.A. MEDICAL BENEFIT PLAN 2013 401k membership |
|---|
| Total participants, beginning-of-year | 2013-07-01 | 215 |
| Total number of active participants reported on line 7a of the Form 5500 | 2013-07-01 | 221 |
| Total of all active and inactive participants | 2013-07-01 | 221 |
| 2012: ARKANSAS UROLOGY, P.A. MEDICAL BENEFIT PLAN 2012 401k membership |
|---|
| Total participants, beginning-of-year | 2012-07-01 | 141 |
| Total number of active participants reported on line 7a of the Form 5500 | 2012-07-01 | 215 |
| Number of retired or separated participants receiving benefits | 2012-07-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2012-07-01 | 0 |
| Total of all active and inactive participants | 2012-07-01 | 215 |
| 2011: ARKANSAS UROLOGY, P.A. MEDICAL BENEFIT PLAN 2011 401k membership |
|---|
| Total participants, beginning-of-year | 2011-07-01 | 128 |
| Total number of active participants reported on line 7a of the Form 5500 | 2011-07-01 | 141 |
| Number of retired or separated participants receiving benefits | 2011-07-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2011-07-01 | 0 |
| Total of all active and inactive participants | 2011-07-01 | 141 |
| 2009: ARKANSAS UROLOGY, P.A. MEDICAL BENEFIT PLAN 2009 401k membership |
|---|
| Total participants, beginning-of-year | 2009-07-01 | 111 |
| Total number of active participants reported on line 7a of the Form 5500 | 2009-07-01 | 124 |
| Number of retired or separated participants receiving benefits | 2009-07-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2009-07-01 | 0 |
| Total of all active and inactive participants | 2009-07-01 | 124 |
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | LIF94049 |
| Policy instance | 10 |
| Insurance contract or identification number | LIF94049 | | Number of Individuals Covered | 21 | | Insurance policy start date | 2021-07-01 | | Insurance policy end date | 2022-06-30 | | Total amount of commissions paid to insurance broker | USD $1,955 | | Total amount of fees paid to insurance company | USD $180 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $21,716 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,458 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 180 |
|
| DELTA DENTAL PLAN OF ARKANSAS (National Association of Insurance Commissioners NAIC id number: 47155 ) |
| Policy contract number | 000004530 |
| Policy instance | 1 |
| Insurance contract or identification number | 000004530 | | Number of Individuals Covered | 432 | | Insurance policy start date | 2021-07-01 | | Insurance policy end date | 2022-06-30 | | 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? | 3 |
|
| ARKANSAS BLUE CROSS BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 83470 ) |
| Policy contract number | 83470 |
| Policy instance | 2 |
| Insurance contract or identification number | 83470 | | Number of Individuals Covered | 230 | | Insurance policy start date | 2021-07-01 | | Insurance policy end date | 2022-06-30 | | Total amount of fees paid to insurance company | USD $199,824 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,539,732 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 199824 | | Additional information about fees paid to insurance broker | MISCELLANEOUS ADMINISTRATIVE | | Insurance broker organization code? | 5 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 000000428300 |
| Policy instance | 3 |
| Insurance contract or identification number | 000000428300 | | Number of Individuals Covered | 288 | | Insurance policy start date | 2021-07-01 | | Insurance policy end date | 2022-06-30 | | Total amount of commissions paid to insurance broker | USD $10,716 | | Total amount of fees paid to insurance company | USD $2,025 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $97,355 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $10,716 | | Amount paid for insurance broker fees | 2025 | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL PLAN OF ARKANSAS (National Association of Insurance Commissioners NAIC id number: 47155 ) |
| Policy contract number | 00004530V |
| Policy instance | 4 |
| Insurance contract or identification number | 00004530V | | Number of Individuals Covered | 315 | | Insurance policy start date | 2021-07-01 | | Insurance policy end date | 2022-06-30 | | Total amount of commissions paid to insurance broker | USD $3,608 | | 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 $3,608 | | Insurance broker organization code? | 3 |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 00557857 |
| Policy instance | 5 |
| Insurance contract or identification number | 00557857 | | Number of Individuals Covered | 131 | | Insurance policy start date | 2021-07-01 | | Insurance policy end date | 2022-06-30 | | Total amount of commissions paid to insurance broker | USD $14,293 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $73,903 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $14,293 | | Additional information about fees paid to insurance broker | MISCELLANEOUS ADMINISTRATIVE | | Insurance broker organization code? | 3 |
|
| MONY (National Association of Insurance Commissioners NAIC id number: 78077 ) |
| Policy contract number | 007842 |
| Policy instance | 6 |
| Insurance contract or identification number | 007842 | | Number of Individuals Covered | 116 | | Insurance policy start date | 2021-07-01 | | Insurance policy end date | 2022-06-30 | | Total amount of commissions paid to insurance broker | USD $15,558 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $63,048 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $15,558 | | Insurance broker organization code? | 3 |
|
| PRE-PAID LEGAL SERVICES DBA LEGAL SHIELD (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 202727 |
| Policy instance | 7 |
| Insurance contract or identification number | 202727 | | Number of Individuals Covered | 20 | | Insurance policy start date | 2021-07-01 | | Insurance policy end date | 2022-06-30 | | Total amount of commissions paid to insurance broker | USD $307 | | Other welfare benefits provided | LEGAL SERVICES PLAN MEMBERSHIPS | | Welfare Benefit Premiums Paid to Carrier | USD $2,685 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $232 | | Insurance broker organization code? | 4 |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 941663 |
| Policy instance | 8 |
| Insurance contract or identification number | 941663 | | Number of Individuals Covered | 242 | | Insurance policy start date | 2021-07-01 | | Insurance policy end date | 2022-06-30 | | Total amount of commissions paid to insurance broker | USD $29,553 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $355,681 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $29,553 |
|
| 5 STAR LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 77879 ) |
| Policy contract number | 02728 |
| Policy instance | 9 |
| Insurance contract or identification number | 02728 | | Number of Individuals Covered | 97 | | Insurance policy start date | 2021-07-01 | | Insurance policy end date | 2022-06-30 | | Total amount of commissions paid to insurance broker | USD $16,835 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | GROUP CRITICAL ILLNESS | | Welfare Benefit Premiums Paid to Carrier | USD $42,083 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $13,280 | | Insurance broker organization code? | 3 |
|
| ARKANSAS BLUE CROSS BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 83470 ) |
| Policy contract number | 83470 |
| Policy instance | 2 |
| Insurance contract or identification number | 83470 | | Number of Individuals Covered | 199 | | Insurance policy start date | 2020-07-01 | | Insurance policy end date | 2021-06-30 | | Total amount of fees paid to insurance company | USD $151,128 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,214,302 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 151128 | | Additional information about fees paid to insurance broker | MISCELLANEOUS ADMINISTRATIVE | | Insurance broker organization code? | 5 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 000000428300 |
| Policy instance | 3 |
| Insurance contract or identification number | 000000428300 | | Number of Individuals Covered | 269 | | Insurance policy start date | 2020-07-01 | | Insurance policy end date | 2021-06-30 | | Total amount of commissions paid to insurance broker | USD $18,054 | | Total amount of fees paid to insurance company | USD $7,222 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $182,748 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $18,054 | | Amount paid for insurance broker fees | 7222 | | Insurance broker organization code? | 3 |
|
| COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 ) |
| Policy contract number | E3955739 |
| Policy instance | 4 |
| Insurance contract or identification number | E3955739 | | Number of Individuals Covered | 138 | | Insurance policy start date | 2020-07-01 | | Insurance policy end date | 2021-06-30 | | Total amount of commissions paid to insurance broker | USD $6,399 | | Total amount of fees paid to insurance company | USD $187 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $22,570 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,393 | | Additional information about fees paid to insurance broker | MISCELLANEOUS ADMINISTRATIVE | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 51 |
|
| DELTA DENTAL PLAN OF ARKANSAS (National Association of Insurance Commissioners NAIC id number: 47155 ) |
| Policy contract number | 00004530V |
| Policy instance | 5 |
| Insurance contract or identification number | 00004530V | | Number of Individuals Covered | 315 | | Insurance policy start date | 2020-07-01 | | Insurance policy end date | 2021-06-30 | | Total amount of commissions paid to insurance broker | USD $2,667 | | 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 $2,667 | | Insurance broker organization code? | 3 |
|
| MONY (National Association of Insurance Commissioners NAIC id number: 78077 ) |
| Policy contract number | 007842 |
| Policy instance | 7 |
| Insurance contract or identification number | 007842 | | Number of Individuals Covered | 104 | | Insurance policy start date | 2020-07-01 | | Insurance policy end date | 2021-07-01 | | Total amount of commissions paid to insurance broker | USD $15,897 | | Total amount of fees paid to insurance company | USD $3,871 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $68,238 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $15,897 | | Amount paid for insurance broker fees | 3871 | | Additional information about fees paid to insurance broker | BONUS | | Insurance broker organization code? | 3 |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 00557857 |
| Policy instance | 6 |
| Insurance contract or identification number | 00557857 | | Number of Individuals Covered | 123 | | Insurance policy start date | 2020-07-01 | | Insurance policy end date | 2021-06-30 | | Total amount of commissions paid to insurance broker | USD $76,142 | | Total amount of fees paid to insurance company | USD $2,513 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $81,096 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $76,142 | | Amount paid for insurance broker fees | 2513 | | Additional information about fees paid to insurance broker | MISCELLANEOUS ADMINISTRATIVE | | Insurance broker organization code? | 3 |
|
| PRE-PAID LEGAL SERVICES DBA LEGAL SHIELD (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 202727 |
| Policy instance | 8 |
| Insurance contract or identification number | 202727 | | Number of Individuals Covered | 17 | | Insurance policy start date | 2020-07-01 | | Insurance policy end date | 2021-06-30 | | Total amount of commissions paid to insurance broker | USD $728 | | Other welfare benefits provided | LEGAL SERVICES PLAN MEMBERSHIPS | | Welfare Benefit Premiums Paid to Carrier | USD $2,455 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $659 | | Insurance broker organization code? | 4 |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | LIF94049 |
| Policy instance | 9 |
| Insurance contract or identification number | LIF94049 | | Number of Individuals Covered | 22 | | Insurance policy start date | 2020-06-01 | | Insurance policy end date | 2021-07-01 | | Total amount of commissions paid to insurance broker | USD $2,267 | | Total amount of fees paid to insurance company | USD $180 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $25,187 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,267 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 180 | | Additional information about fees paid to insurance broker | ADMINISTRATIVE FEE |
|
| 5 STAR LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 77879 ) |
| Policy contract number | 02728 |
| Policy instance | 10 |
| Insurance contract or identification number | 02728 | | Number of Individuals Covered | 101 | | Insurance policy start date | 2020-07-01 | | Insurance policy end date | 2021-06-30 | | Total amount of commissions paid to insurance broker | USD $11,675 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | GROUP CRITICAL ILLNESS | | Welfare Benefit Premiums Paid to Carrier | USD $6,292 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $11,334 | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL PLAN OF ARKANSAS (National Association of Insurance Commissioners NAIC id number: 47155 ) |
| Policy contract number | 000004530 |
| Policy instance | 1 |
| Insurance contract or identification number | 000004530 | | Number of Individuals Covered | 356 | | Insurance policy start date | 2020-07-01 | | Insurance policy end date | 2021-06-30 | | 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? | 3 |
|
| DELTA DENTAL PLAN OF ARKANSAS (National Association of Insurance Commissioners NAIC id number: 47155 ) |
| Policy contract number | 000004530 |
| Policy instance | 1 |
| Insurance contract or identification number | 000004530 | | Number of Individuals Covered | 265 | | Insurance policy start date | 2019-07-01 | | Insurance policy end date | 2020-06-30 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| ARKANSAS BLUE CROSS BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 83470 ) |
| Policy contract number | 83470 |
| Policy instance | 2 |
| Insurance contract or identification number | 83470 | | Number of Individuals Covered | 172 | | Insurance policy start date | 2019-07-01 | | Insurance policy end date | 2020-06-30 | | Total amount of fees paid to insurance company | USD $115,301 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,120,680 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 115301 | | Additional information about fees paid to insurance broker | MISCELLANEOUS ADMINISTRATIVE | | Insurance broker organization code? | 5 |
|
| QBE A&H (National Association of Insurance Commissioners NAIC id number: 10219 ) |
| Policy contract number | LGS01081-17 |
| Policy instance | 3 |
| Insurance contract or identification number | LGS01081-17 | | Number of Individuals Covered | 167 | | Insurance policy start date | 2019-07-01 | | Insurance policy end date | 2020-06-30 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $241,936 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 ) |
| Policy contract number | E3955739 |
| Policy instance | 4 |
| Insurance contract or identification number | E3955739 | | Number of Individuals Covered | 131 | | Insurance policy start date | 2019-07-01 | | Insurance policy end date | 2020-06-30 | | Total amount of commissions paid to insurance broker | USD $33,541 | | Total amount of fees paid to insurance company | USD $1,252 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $116,932 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $12,463 | | Additional information about fees paid to insurance broker | MISCELLANEOUS ADMINISTRATIVE | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 764 |
|
| DELTA DENTAL PLAN OF ARKANSAS (National Association of Insurance Commissioners NAIC id number: 47155 ) |
| Policy contract number | 00004530V |
| Policy instance | 5 |
| Insurance contract or identification number | 00004530V | | Number of Individuals Covered | 251 | | Insurance policy start date | 2019-07-01 | | Insurance policy end date | 2020-06-30 | | Total amount of commissions paid to insurance broker | USD $2,177 | | 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 $2,177 | | Additional information about fees paid to insurance broker | MISCELLANEOUS ADMINISTRATIVE | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL PLAN OF ARKANSAS (National Association of Insurance Commissioners NAIC id number: 47155 ) |
| Policy contract number | 00004530V |
| Policy instance | 5 |
| Insurance contract or identification number | 00004530V | | Number of Individuals Covered | 251 | | Insurance policy start date | 2018-07-01 | | Insurance policy end date | 2019-06-30 | | Total amount of commissions paid to insurance broker | USD $2,177 | | 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 $2,177 | | Additional information about fees paid to insurance broker | MISCELLANEOUS ADMINISTRATIVE | | Insurance broker organization code? | 3 |
|
| COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 ) |
| Policy contract number | E3955739 |
| Policy instance | 4 |
| Insurance contract or identification number | E3955739 | | Number of Individuals Covered | 131 | | Insurance policy start date | 2018-07-01 | | Insurance policy end date | 2019-06-30 | | Total amount of commissions paid to insurance broker | USD $33,541 | | Total amount of fees paid to insurance company | USD $1,252 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $116,932 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $12,463 | | Additional information about fees paid to insurance broker | MISCELLANEOUS ADMINISTRATIVE | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 764 |
|
| QBE A&H (National Association of Insurance Commissioners NAIC id number: 10219 ) |
| Policy contract number | LGS01081-17 |
| Policy instance | 3 |
| Insurance contract or identification number | LGS01081-17 | | Number of Individuals Covered | 167 | | Insurance policy start date | 2018-07-01 | | Insurance policy end date | 2019-06-30 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $241,936 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| ARKANSAS BLUE CROSS BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 83470 ) |
| Policy contract number | 83470 |
| Policy instance | 2 |
| Insurance contract or identification number | 83470 | | Number of Individuals Covered | 172 | | Insurance policy start date | 2018-07-01 | | Insurance policy end date | 2019-06-30 | | Total amount of fees paid to insurance company | USD $115,301 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,120,680 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 115301 | | Additional information about fees paid to insurance broker | MISCELLANEOUS ADMINISTRATIVE | | Insurance broker organization code? | 5 |
|
| DELTA DENTAL PLAN OF ARKANSAS (National Association of Insurance Commissioners NAIC id number: 47155 ) |
| Policy contract number | 000004530 |
| Policy instance | 1 |
| Insurance contract or identification number | 000004530 | | Number of Individuals Covered | 265 | | Insurance policy start date | 2018-07-01 | | Insurance policy end date | 2019-06-30 | | 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? | 3 |
|
| COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 ) |
| Policy contract number | E3955739 |
| Policy instance | 5 |
| Insurance contract or identification number | E3955739 | | Number of Individuals Covered | 107 | | Insurance policy start date | 2017-07-01 | | Insurance policy end date | 2018-06-30 | | Total amount of commissions paid to insurance broker | USD $20,153 | | Total amount of fees paid to insurance company | USD $1,163 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $86,497 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,224 | | Amount paid for insurance broker fees | 64 | | Additional information about fees paid to insurance broker | MISCELLANEOUS ADMINISTRATIVE | | Insurance broker organization code? | 3 | | Insurance broker name | JENNIFER HUNTER |
|
| QBE A&H (National Association of Insurance Commissioners NAIC id number: 10219 ) |
| Policy contract number | LGS01081-17 |
| Policy instance | 4 |
| Insurance contract or identification number | LGS01081-17 | | Number of Individuals Covered | 143 | | Insurance policy start date | 2017-07-01 | | Insurance policy end date | 2018-06-30 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $197,521 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| ARKANSAS BLUE CROSS BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 83470 ) |
| Policy contract number | 83470 |
| Policy instance | 3 |
| Insurance contract or identification number | 83470 | | Number of Individuals Covered | 157 | | Insurance policy start date | 2017-07-01 | | Insurance policy end date | 2018-06-30 | | Total amount of fees paid to insurance company | USD $97,228 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $717,249 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 97228 | | Additional information about fees paid to insurance broker | MISCELLANEOUS ADMINISTRATIVE | | Insurance broker organization code? | 5 | | Insurance broker name | BLUEADVANTAGE ADMINISTRATORS OF ARK |
|
| DELTA DENTAL PLAN OF ARKANSAS (National Association of Insurance Commissioners NAIC id number: 47155 ) |
| Policy contract number | 000004530 |
| Policy instance | 2 |
| Insurance contract or identification number | 000004530 | | Number of Individuals Covered | 242 | | Insurance policy start date | 2017-07-01 | | Insurance policy end date | 2018-06-30 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 12289209 |
| Policy instance | 1 |
| Insurance contract or identification number | 12289209 | | Number of Individuals Covered | 126 | | Insurance policy start date | 2017-07-01 | | Insurance policy end date | 2018-06-30 | | Total amount of commissions paid to insurance broker | USD $1,384 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $23,330 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,384 | | Insurance broker organization code? | 3 | | Insurance broker name | JTS FINANCIAL SERVICES, LLC |
|
| QBE A&H (National Association of Insurance Commissioners NAIC id number: 10219 ) |
| Policy contract number | LGS01081-14 |
| Policy instance | 5 |
| Insurance contract or identification number | LGS01081-14 | | Number of Individuals Covered | 1458 | | Insurance policy start date | 2015-07-01 | | Insurance policy end date | 2016-06-30 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $147,977 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| ARKANSAS BLUE CROSS BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 83470 ) |
| Policy contract number | 83470 |
| Policy instance | 4 |
| Insurance contract or identification number | 83470 | | Number of Individuals Covered | 120 | | Insurance policy start date | 2015-07-01 | | Insurance policy end date | 2016-06-30 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $81,034 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 ) |
| Policy contract number | 1045110 |
| Policy instance | 3 |
| Insurance contract or identification number | 1045110 | | Number of Individuals Covered | 142 | | Insurance policy start date | 2015-07-01 | | Insurance policy end date | 2016-06-30 | | Total amount of commissions paid to insurance broker | USD $12,258 | | Total amount of fees paid to insurance company | USD $373 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $120,476 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,755 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 373 | | Additional information about fees paid to insurance broker | BONUS | | Insurance broker name | ACRISURE LLC |
|
| DELTA DENTAL PLAN OF ARKANSAS (National Association of Insurance Commissioners NAIC id number: 47155 ) |
| Policy contract number | 000004530 |
| Policy instance | 2 |
| Insurance contract or identification number | 000004530 | | Number of Individuals Covered | 207 | | Insurance policy start date | 2015-07-01 | | Insurance policy end date | 2016-06-30 | | 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? | 3 | | Insurance broker name | JTS FINANCIAL SERVICES |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 12289209 |
| Policy instance | 1 |
| Insurance contract or identification number | 12289209 | | Number of Individuals Covered | 99 | | Insurance policy start date | 2015-07-01 | | Insurance policy end date | 2016-06-30 | | Total amount of commissions paid to insurance broker | USD $1,029 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $18,320 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,029 | | Insurance broker organization code? | 3 | | Insurance broker name | JTS FINANCIAL SERVICES, LLC |
|
| COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 ) |
| Policy contract number | E3955739 |
| Policy instance | 6 |
| Insurance contract or identification number | E3955739 | | Number of Individuals Covered | 85 | | Insurance policy start date | 2015-07-01 | | Insurance policy end date | 2016-06-30 | | Total amount of commissions paid to insurance broker | USD $20,947 | | Total amount of fees paid to insurance company | USD $684 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $87,098 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,539 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 182 | | Additional information about fees paid to insurance broker | MISC | | Insurance broker name | BARNETT BENEFITS GROUP INC |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 12289209 |
| Policy instance | 1 |
| Insurance contract or identification number | 12289209 | | Number of Individuals Covered | 124 | | Insurance policy start date | 2014-07-01 | | Insurance policy end date | 2015-06-30 | | Total amount of commissions paid to insurance broker | USD $1,077 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $18,414 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,077 | | Insurance broker organization code? | 3 | | Insurance broker name | JTS FINANCIAL SERVICES, LLC |
|
| DELTA DENTAL PLAN OF ARKANSAS (National Association of Insurance Commissioners NAIC id number: 47155 ) |
| Policy contract number | 000004530 |
| Policy instance | 2 |
| Insurance contract or identification number | 000004530 | | Number of Individuals Covered | 230 | | Insurance policy start date | 2014-07-01 | | Insurance policy end date | 2015-06-30 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 ) |
| Policy contract number | 1045110 |
| Policy instance | 3 |
| Insurance contract or identification number | 1045110 | | Number of Individuals Covered | 158 | | Insurance policy start date | 2014-07-01 | | Insurance policy end date | 2015-06-30 | | Total amount of commissions paid to insurance broker | USD $10,774 | | Total amount of fees paid to insurance company | USD $4,784 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $105,932 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $10,774 | | Amount paid for insurance broker fees | 4784 | | Additional information about fees paid to insurance broker | BONUS | | Insurance broker organization code? | 3 | | Insurance broker name | THE HATCHER AGENCY |
|
| ARKANSAS BLUE CROSS BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 83470 ) |
| Policy contract number | 83470 |
| Policy instance | 4 |
| Insurance contract or identification number | 83470 | | Number of Individuals Covered | 138 | | Insurance policy start date | 2014-07-01 | | Insurance policy end date | 2015-06-30 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $83,354 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| QBE A&H (National Association of Insurance Commissioners NAIC id number: 10219 ) |
| Policy contract number | LGS01081-14 |
| Policy instance | 5 |
| Insurance contract or identification number | LGS01081-14 | | Number of Individuals Covered | 985 | | Insurance policy start date | 2014-07-01 | | Insurance policy end date | 2015-06-30 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $120,160 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 12289209 |
| Policy instance | 2 |
| Insurance contract or identification number | 12289209 | | Number of Individuals Covered | 88 | | Insurance policy start date | 2013-07-01 | | Insurance policy end date | 2014-06-30 | | Total amount of commissions paid to insurance broker | USD $954 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $15,527 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $954 | | Insurance broker organization code? | 3 | | Insurance broker name | JTS FINANCIAL SERVICES, LLC |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | R0100123 |
| Policy instance | 1 |
| Insurance contract or identification number | R0100123 | | Number of Individuals Covered | 134 | | Insurance policy start date | 2013-07-01 | | Insurance policy end date | 2014-06-30 | | Total amount of commissions paid to insurance broker | USD $456 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $4,546 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $456 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | JOHN THOMAS STARLING |
|
| DELTA DENTAL PLAN OF ARKANSAS (National Association of Insurance Commissioners NAIC id number: 47155 ) |
| Policy contract number | 000004530 |
| Policy instance | 3 |
| Insurance contract or identification number | 000004530 | | Number of Individuals Covered | 221 | | Insurance policy start date | 2013-07-01 | | Insurance policy end date | 2014-06-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Dental Insurance Welfare Benefit | Yes | | 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 | HCL30526 |
| Policy instance | 5 |
| Insurance contract or identification number | HCL30526 | | Number of Individuals Covered | 135 | | Insurance policy start date | 2013-07-01 | | Insurance policy end date | 2014-06-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Welfare Benefit Premiums Paid to Carrier | USD $157,506 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| QCA HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 95448 ) |
| Policy contract number | 90002 |
| Policy instance | 4 |
| Insurance contract or identification number | 90002 | | Number of Individuals Covered | 202 | | Insurance policy start date | 2013-07-01 | | Insurance policy end date | 2014-06-30 | | Total amount of commissions paid to insurance broker | USD $14,918 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $44,948 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $14,918 | | Additional information about fees paid to insurance broker | ADMINISTRATIVE FEES | | Insurance broker organization code? | 3 | | Insurance broker name | JTS FINANCIAL SERVICES, LLC |
|
| QCA HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 95448 ) |
| Policy contract number | 90002 |
| Policy instance | 4 |
| Insurance contract or identification number | 90002 | | Number of Individuals Covered | 207 | | Insurance policy start date | 2012-07-01 | | Insurance policy end date | 2013-06-30 | | Total amount of commissions paid to insurance broker | USD $15,709 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $44,072 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $15,709 | | Insurance broker organization code? | 3 | | Insurance broker name | JTS FINANCIAL SERVICES, LLC |
|
| DELTA DENTAL PLAN OF ARKANSAS (National Association of Insurance Commissioners NAIC id number: 47155 ) |
| Policy contract number | 000004530 |
| Policy instance | 3 |
| Insurance contract or identification number | 000004530 | | Number of Individuals Covered | 215 | | Insurance policy start date | 2012-07-01 | | Insurance policy end date | 2013-06-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 12289209 |
| Policy instance | 2 |
| Insurance contract or identification number | 12289209 | | Number of Individuals Covered | 90 | | Insurance policy start date | 2012-07-01 | | Insurance policy end date | 2013-06-30 | | Total amount of commissions paid to insurance broker | USD $912 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $14,797 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $787 | | Insurance broker organization code? | 3 | | Insurance broker name | PINNACLE BENEFIT SOLUTIONS LLC |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | R0100123 |
| Policy instance | 1 |
| Insurance contract or identification number | R0100123 | | Number of Individuals Covered | 140 | | Insurance policy start date | 2012-07-01 | | Insurance policy end date | 2013-06-30 | | Total amount of commissions paid to insurance broker | USD $451 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $4,511 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $412 | | Insurance broker organization code? | 3 | | Insurance broker name | PINNACLE BENEFIT SOLUTIONS LLC |
|
| HCC LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 92711 ) |
| Policy contract number | HCL12884 |
| Policy instance | 3 |
| Insurance contract or identification number | HCL12884 | | Number of Individuals Covered | 141 | | Insurance policy start date | 2011-07-01 | | Insurance policy end date | 2012-06-30 | | Total amount of commissions paid to insurance broker | USD $28,655 | | Total amount of fees paid to insurance company | USD $4,202 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $210,095 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 12289209 |
| Policy instance | 2 |
| Insurance contract or identification number | 12289209 | | Number of Individuals Covered | 97 | | Insurance policy start date | 2011-07-01 | | Insurance policy end date | 2012-06-30 | | Total amount of commissions paid to insurance broker | USD $132 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $14,962 | | 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 | R0100123 |
| Policy instance | 1 |
| Insurance contract or identification number | R0100123 | | Number of Individuals Covered | 140 | | Insurance policy start date | 2011-07-01 | | Insurance policy end date | 2012-06-30 | | Total amount of commissions paid to insurance broker | USD $450 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $4,498 | | 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 | HCL12884 |
| Policy instance | 3 |
| Insurance contract or identification number | HCL12884 | | Number of Individuals Covered | 128 | | Insurance policy start date | 2010-07-01 | | Insurance policy end date | 2011-06-30 | | Total amount of commissions paid to insurance broker | USD $29,565 | | Total amount of fees paid to insurance company | USD $4,106 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $205,306 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $29,565 | | Amount paid for insurance broker fees | 4106 | | Additional information about fees paid to insurance broker | OVERRIDE FEE | | Insurance broker organization code? | 5 | | Insurance broker name | CORESOURCE, INC. |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 12289209 |
| Policy instance | 2 |
| Insurance contract or identification number | 12289209 | | Number of Individuals Covered | 81 | | Insurance policy start date | 2010-07-01 | | Insurance policy end date | 2011-06-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $12,298 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 ) |
| Policy contract number | R0100123 |
| Policy instance | 1 |
| Insurance contract or identification number | R0100123 | | Number of Individuals Covered | 122 | | Insurance policy start date | 2010-07-01 | | Insurance policy end date | 2011-06-30 | | Total amount of commissions paid to insurance broker | USD $404 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $4,388 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $404 | | Insurance broker organization code? | 5 | | Insurance broker name | CORESOURCE, INC. |
|
