PAY-LESS SUPERMARKET, INC has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan PAY-LESS SUPERMARKET, INC. EMPLOYEE BENEFITS PLAN
401k plan membership statisitcs for PAY-LESS SUPERMARKET, INC. EMPLOYEE BENEFITS PLAN
| Measure | Date | Value |
|---|
| 2016: PAY-LESS SUPERMARKET, INC. EMPLOYEE BENEFITS PLAN 2016 401k membership |
|---|
| Total participants, beginning-of-year | 2016-06-01 | 297 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-06-01 | 250 |
| Total of all active and inactive participants | 2016-06-01 | 250 |
| Total participants | 2016-06-01 | 250 |
| 2015: PAY-LESS SUPERMARKET, INC. EMPLOYEE BENEFITS PLAN 2015 401k membership |
|---|
| Total participants, beginning-of-year | 2015-06-01 | 288 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-06-01 | 279 |
| Number of retired or separated participants receiving benefits | 2015-06-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2015-06-01 | 10 |
| Total of all active and inactive participants | 2015-06-01 | 289 |
| 2014: PAY-LESS SUPERMARKET, INC. EMPLOYEE BENEFITS PLAN 2014 401k membership |
|---|
| Total participants, beginning-of-year | 2014-06-01 | 268 |
| Total number of active participants reported on line 7a of the Form 5500 | 2014-06-01 | 262 |
| Number of retired or separated participants receiving benefits | 2014-06-01 | 4 |
| Number of other retired or separated participants entitled to future benefits | 2014-06-01 | 26 |
| Total of all active and inactive participants | 2014-06-01 | 292 |
| 2013: PAY-LESS SUPERMARKET, INC. EMPLOYEE BENEFITS PLAN 2013 401k membership |
|---|
| Total participants, beginning-of-year | 2013-06-01 | 269 |
| Total number of active participants reported on line 7a of the Form 5500 | 2013-06-01 | 192 |
| Number of retired or separated participants receiving benefits | 2013-06-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2013-06-01 | 0 |
| Total of all active and inactive participants | 2013-06-01 | 192 |
| 2012: PAY-LESS SUPERMARKET, INC. EMPLOYEE BENEFITS PLAN 2012 401k membership |
|---|
| Total participants, beginning-of-year | 2012-06-01 | 213 |
| Total number of active participants reported on line 7a of the Form 5500 | 2012-06-01 | 269 |
| Number of retired or separated participants receiving benefits | 2012-06-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2012-06-01 | 0 |
| Total of all active and inactive participants | 2012-06-01 | 269 |
| 2016: PAY-LESS SUPERMARKET, INC. EMPLOYEE BENEFITS PLAN 2016 form 5500 responses |
|---|
| 2016-06-01 | Type of plan entity | Single employer plan |
| 2016-06-01 | This submission is the final filing | Yes |
| 2016-06-01 | This return/report is a short plan year return/report (less than 12 months) | Yes |
| 2016-06-01 | Plan funding arrangement – Insurance | Yes |
| 2016-06-01 | Plan benefit arrangement – Insurance | Yes |
| 2015: PAY-LESS SUPERMARKET, INC. EMPLOYEE BENEFITS PLAN 2015 form 5500 responses |
|---|
| 2015-06-01 | Type of plan entity | Single employer plan |
| 2015-06-01 | Submission has been amended | No |
| 2015-06-01 | This submission is the final filing | No |
| 2015-06-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2015-06-01 | Plan is a collectively bargained plan | No |
| 2015-06-01 | Plan funding arrangement – Insurance | Yes |
| 2015-06-01 | Plan benefit arrangement – Insurance | Yes |
| 2014: PAY-LESS SUPERMARKET, INC. EMPLOYEE BENEFITS PLAN 2014 form 5500 responses |
|---|
| 2014-06-01 | Type of plan entity | Single employer plan |
| 2014-06-01 | Submission has been amended | No |
| 2014-06-01 | This submission is the final filing | No |
| 2014-06-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2014-06-01 | Plan is a collectively bargained plan | No |
| 2014-06-01 | Plan funding arrangement – Insurance | Yes |
| 2014-06-01 | Plan benefit arrangement – Insurance | Yes |
| 2013: PAY-LESS SUPERMARKET, INC. EMPLOYEE BENEFITS PLAN 2013 form 5500 responses |
|---|
| 2013-06-01 | Type of plan entity | Single employer plan |
| 2013-06-01 | Submission has been amended | No |
| 2013-06-01 | This submission is the final filing | No |
| 2013-06-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2013-06-01 | Plan is a collectively bargained plan | No |
| 2013-06-01 | Plan funding arrangement – Insurance | Yes |
| 2013-06-01 | Plan benefit arrangement – Insurance | Yes |
| 2012: PAY-LESS SUPERMARKET, INC. EMPLOYEE BENEFITS PLAN 2012 form 5500 responses |
|---|
| 2012-06-01 | Type of plan entity | Single employer plan |
| 2012-06-01 | First time form 5500 has been submitted | Yes |
| 2012-06-01 | Submission has been amended | No |
| 2012-06-01 | This submission is the final filing | No |
| 2012-06-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2012-06-01 | Plan is a collectively bargained plan | No |
| 2012-06-01 | Plan funding arrangement – Insurance | Yes |
| 2012-06-01 | Plan benefit arrangement – Insurance | Yes |
| BLUE CROSS BLUE SHIELD OF LOUISIANA (National Association of Insurance Commissioners NAIC id number: 81200 ) |
| Policy contract number | 78E03ERC |
| Policy instance | 3 |
| Insurance contract or identification number | 78E03ERC | | Number of Individuals Covered | 279 | | Insurance policy start date | 2015-06-01 | | Insurance policy end date | 2016-05-31 | | Total amount of commissions paid to insurance broker | USD $100,563 | | Total amount of fees paid to insurance company | USD $46,391 | | 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 $100,563 | | Amount paid for insurance broker fees | 46391 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker organization code? | 3 | | Insurance broker name | HUB INTERNATIONAL GULF SOUTH LTD |
|
| MERITAIN HEALTH (National Association of Insurance Commissioners NAIC id number: 77828 ) |
| Policy contract number | D4143, 9671215 |
| Policy instance | 2 |
| Insurance contract or identification number | D4143, 9671215 | | Number of Individuals Covered | 189 | | Insurance policy start date | 2015-03-01 | | Insurance policy end date | 2016-02-29 | | Total amount of commissions paid to insurance broker | USD $10,147 | | Total amount of fees paid to insurance company | USD $12,767 | | 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 | 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 $101,463 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 7257 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker organization code? | 3 | | Commission paid to Insurance Broker | USD $4,059 | | Insurance broker name | JOSEPH SHAW |
|
| AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 ) |
| Policy contract number | AG542 |
| Policy instance | 1 |
| Insurance contract or identification number | AG542 | | Number of Individuals Covered | 175 | | Insurance policy start date | 2015-03-01 | | Insurance policy end date | 2016-02-29 | | Total amount of commissions paid to insurance broker | USD $21,129 | | Total amount of fees paid to insurance company | 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 | 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 $107,103 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $11,376 | | Insurance broker organization code? | 3 | | Insurance broker name | BRADLEY BAROUSSE |
|
| MERITAIN HEALTH (National Association of Insurance Commissioners NAIC id number: 77828 ) |
| Policy contract number | D4143 9671215 |
| Policy instance | 4 |
| Insurance contract or identification number | D4143 9671215 | | Number of Individuals Covered | 153 | | Insurance policy start date | 2014-03-01 | | Insurance policy end date | 2015-02-28 | | Total amount of commissions paid to insurance broker | USD $3,205 | | Total amount of fees paid to insurance company | USD $4,073 | | 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 | 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 $32,053 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 2326 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker organization code? | 3 | | Commission paid to Insurance Broker | USD $1,282 | | Insurance broker name | JOSEPH SHAW |
|
| BLUE CROSS BLUE SHIELD OF LOUISIANA (National Association of Insurance Commissioners NAIC id number: 81200 ) |
| Policy contract number | 78E03ERC |
| Policy instance | 3 |
| Insurance contract or identification number | 78E03ERC | | Number of Individuals Covered | 262 | | Insurance policy start date | 2014-06-01 | | Insurance policy end date | 2015-05-31 | | Total amount of commissions paid to insurance broker | USD $140,556 | | Total amount of fees paid to insurance company | 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 | 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 $140,556 | | Insurance broker organization code? | 3 | | Insurance broker name | HUB INTERNATIONAL GULF SOUTH LTD |
|
| MERITAIN HEALTH (National Association of Insurance Commissioners NAIC id number: 77828 ) |
| Policy contract number | 000000000000000 |
| Policy instance | 2 |
| Insurance contract or identification number | 000000000000000 | | Number of Individuals Covered | 153 | | Insurance policy start date | 2013-09-01 | | Insurance policy end date | 2014-02-28 | | Total amount of commissions paid to insurance broker | USD $3,205 | | Total amount of fees paid to insurance company | USD $4,073 | | 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 | 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 $32,054 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 2326 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker organization code? | 3 | | Commission paid to Insurance Broker | USD $1,282 | | Insurance broker name | JOSEPH SHAW |
|
| AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 ) |
| Policy contract number | AG542 |
| Policy instance | 1 |
| Insurance contract or identification number | AG542 | | Number of Individuals Covered | 171 | | Insurance policy start date | 2014-03-01 | | Insurance policy end date | 2015-02-28 | | Total amount of commissions paid to insurance broker | USD $26,309 | | Total amount of fees paid to insurance company | 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 | Yes | | 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 | | Other welfare benefits provided | ACCIDENT, CANCER, HEART/STROKE | | 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 $101,938 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $14,656 | | Insurance broker organization code? | 3 | | Insurance broker name | BRIAN H BORDES |
|
| BLUE CROSS BLUE SHIELD OF LOUISIANA (National Association of Insurance Commissioners NAIC id number: 81200 ) |
| Policy contract number | 78E03ERC |
| Policy instance | 3 |
| Insurance contract or identification number | 78E03ERC | | Number of Individuals Covered | 192 | | Insurance policy start date | 2013-06-01 | | Insurance policy end date | 2014-05-31 | | Total amount of commissions paid to insurance broker | USD $79,427 | | Total amount of fees paid to insurance company | 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 | 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 $1,538,727 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $59,643 | | Insurance broker organization code? | 3 | | Insurance broker name | GROUP INSURANCE INC. OF LOUISIANA |
|
| MERITAIN HEALTH (National Association of Insurance Commissioners NAIC id number: 77828 ) |
| Policy contract number | 000000000000000 |
| Policy instance | 2 |
| Insurance contract or identification number | 000000000000000 | | Number of Individuals Covered | 122 | | Insurance policy start date | 2012-09-01 | | Insurance policy end date | 2013-08-31 | | Total amount of commissions paid to insurance broker | USD $6,044 | | Total amount of fees paid to insurance company | 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 | 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 $60,444 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,301 | | Insurance broker organization code? | 3 | | Insurance broker name | KIMBERLY BAROUSSE |
|
| AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 ) |
| Policy contract number | AG542 |
| Policy instance | 1 |
| Insurance contract or identification number | AG542 | | Number of Individuals Covered | 155 | | Insurance policy start date | 2013-03-01 | | Insurance policy end date | 2014-02-28 | | Total amount of commissions paid to insurance broker | USD $20,724 | | Total amount of fees paid to insurance company | 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 | Yes | | 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 $86,897 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,737 | | Insurance broker organization code? | 3 | | Insurance broker name | BRIAN H BORDES |
|
| COVENTRY HEALTH CARE OF LOUISIANA (National Association of Insurance Commissioners NAIC id number: 95173 ) |
| Policy contract number | 6901330000 |
| Policy instance | 3 |
| Insurance contract or identification number | 6901330000 | | Number of Individuals Covered | 269 | | Insurance policy start date | 2012-06-01 | | Insurance policy end date | 2013-05-31 | | Total amount of commissions paid to insurance broker | USD $58,060 | | Total amount of fees paid to insurance company | USD $6,531 | | 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 $1,161,196 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $58,060 | | Amount paid for insurance broker fees | 6531 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker organization code? | 3 | | Insurance broker name | GROUP INSURANCE INCORPORATED |
|
| CONVENTRY HEALTH AND LIFE (National Association of Insurance Commissioners NAIC id number: 81973 ) |
| Policy contract number | 6901330000 |
| Policy instance | 4 |
| Insurance contract or identification number | 6901330000 | | Number of Individuals Covered | 0 | | Insurance policy start date | 2012-06-01 | | Insurance policy end date | 2013-05-31 | | Total amount of commissions paid to insurance broker | USD $280 | | Total amount of fees paid to insurance company | USD $9,439 | | 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 $5,602 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $280 | | Amount paid for insurance broker fees | 9439 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker organization code? | 3 | | Insurance broker name | GROUP INSURANCE INCORPORATED |
|
| MERITAIN HEALTH (National Association of Insurance Commissioners NAIC id number: 77828 ) |
| Policy contract number | 000000000000000 |
| Policy instance | 2 |
| Insurance contract or identification number | 000000000000000 | | Number of Individuals Covered | 117 | | Insurance policy start date | 2011-09-01 | | Insurance policy end date | 2012-08-31 | | Total amount of commissions paid to insurance broker | USD $5,702 | | Total amount of fees paid to insurance company | 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 | 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 $57,019 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,124 | | Insurance broker organization code? | 3 | | Insurance broker name | KIMBERLY BAROUSSE |
|
| AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 ) |
| Policy contract number | AG542 |
| Policy instance | 1 |
| Insurance contract or identification number | AG542 | | Number of Individuals Covered | 143 | | Insurance policy start date | 2012-03-01 | | Insurance policy end date | 2013-02-28 | | Total amount of commissions paid to insurance broker | USD $9,808 | | Total amount of fees paid to insurance company | 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 | Yes | | 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 $75,967 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,353 | | Insurance broker organization code? | 3 | | Insurance broker name | HUB INTL MIDWEST LTD DBA INTERNATIO |
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