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REVIONICS, INC. HEALTH AND WELFARE PLAN 401k Plan overview

Plan NameREVIONICS, INC. HEALTH AND WELFARE PLAN
Plan identification number 501

REVIONICS, INC. HEALTH AND WELFARE PLAN Benefits

401k Plan TypeWelfare Benefit
Plan Features/Benefits
  • Health (other than dental or vision)
  • Life insurance
  • Dental
  • Vision
  • Temporary disability (accident and sickness)
  • Long-term disability cover
  • Death benefits (include travel accident but not life insurance)
  • Other welfare benefit cover
  • Unfunded, fully insured, or combination unfunded/insured welfare plan that will not file a Form 5500 for next plan year pursuant to 29 CFR 2520.104-20.

401k Sponsoring company profile

REVIONICS, INC. has sponsored the creation of one or more 401k plans.

Company Name:REVIONICS, INC.
Employer identification number (EIN):721528091
NAIC Classification:541511
NAIC Description:Custom Computer Programming Services

Additional information about REVIONICS, INC.

Jurisdiction of Incorporation: State of Delaware Division of Corporations
Incorporation Date:
Company Identification Number: 3533104

More information about REVIONICS, INC.

Form 5500 Filing Information

Submission information for form 5500 for 401k plan REVIONICS, INC. HEALTH AND WELFARE PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5012021-01-01LISA ROBINSON2022-09-23
5012020-01-01LISA ROBINSON2021-09-22
5012019-01-01VALERIE MIELE2020-07-07
5012018-01-01BRIAN HANSEN2019-09-16
5012017-11-01
5012016-11-01
5012016-01-01CHANTAL DUGUAY CHANTAL DUGUAY2017-06-16
5012015-11-01CHANTAL DUGUAY
5012015-01-01CHANTEL DUGUAY
5012014-11-01CHANTAL DUGUAY
5012014-01-01BRIAN HANSEN

Plan Statistics for REVIONICS, INC. HEALTH AND WELFARE PLAN

401k plan membership statisitcs for REVIONICS, INC. HEALTH AND WELFARE PLAN

Measure Date Value
2021: REVIONICS, INC. HEALTH AND WELFARE PLAN 2021 401k membership
Total participants, beginning-of-year2021-01-01114
Total number of active participants reported on line 7a of the Form 55002021-01-0196
Number of retired or separated participants receiving benefits2021-01-010
Number of other retired or separated participants entitled to future benefits2021-01-010
Total of all active and inactive participants2021-01-0196
Number of employers contributing to the scheme2021-01-010
2020: REVIONICS, INC. HEALTH AND WELFARE PLAN 2020 401k membership
Total participants, beginning-of-year2020-01-01124
Total number of active participants reported on line 7a of the Form 55002020-01-01109
Number of retired or separated participants receiving benefits2020-01-015
Number of other retired or separated participants entitled to future benefits2020-01-010
Total of all active and inactive participants2020-01-01114
Number of employers contributing to the scheme2020-01-010
2019: REVIONICS, INC. HEALTH AND WELFARE PLAN 2019 401k membership
Total participants, beginning-of-year2019-01-01128
Total number of active participants reported on line 7a of the Form 55002019-01-01124
Number of retired or separated participants receiving benefits2019-01-014
Number of other retired or separated participants entitled to future benefits2019-01-015
Total of all active and inactive participants2019-01-01133
Number of employers contributing to the scheme2019-01-010
2018: REVIONICS, INC. HEALTH AND WELFARE PLAN 2018 401k membership
Total participants, beginning-of-year2018-01-01115
Total number of active participants reported on line 7a of the Form 55002018-01-01115
Number of retired or separated participants receiving benefits2018-01-010
Number of other retired or separated participants entitled to future benefits2018-01-010
Total of all active and inactive participants2018-01-01115
Number of employers contributing to the scheme2018-01-010
2017: REVIONICS, INC. HEALTH AND WELFARE PLAN 2017 401k membership
Total participants, beginning-of-year2017-11-01145
Total number of active participants reported on line 7a of the Form 55002017-11-01129
Number of retired or separated participants receiving benefits2017-11-010
Number of other retired or separated participants entitled to future benefits2017-11-010
Total of all active and inactive participants2017-11-01129
2016: REVIONICS, INC. HEALTH AND WELFARE PLAN 2016 401k membership
Total participants, beginning-of-year2016-11-01145
Total number of active participants reported on line 7a of the Form 55002016-11-01129
Number of retired or separated participants receiving benefits2016-11-013
Number of other retired or separated participants entitled to future benefits2016-11-010
Total of all active and inactive participants2016-11-01132
Total participants, beginning-of-year2016-01-01157
Total number of active participants reported on line 7a of the Form 55002016-01-01145
Number of retired or separated participants receiving benefits2016-01-010
Number of other retired or separated participants entitled to future benefits2016-01-010
Total of all active and inactive participants2016-01-01145
2015: REVIONICS, INC. HEALTH AND WELFARE PLAN 2015 401k membership
Total participants, beginning-of-year2015-11-01157
Total number of active participants reported on line 7a of the Form 55002015-11-01157
Number of retired or separated participants receiving benefits2015-11-010
Number of other retired or separated participants entitled to future benefits2015-11-010
Total of all active and inactive participants2015-11-01157
Total participants, beginning-of-year2015-01-01198
Total number of active participants reported on line 7a of the Form 55002015-01-01148
Number of retired or separated participants receiving benefits2015-01-015
Number of other retired or separated participants entitled to future benefits2015-01-010
Total of all active and inactive participants2015-01-01153
2014: REVIONICS, INC. HEALTH AND WELFARE PLAN 2014 401k membership
Total participants, beginning-of-year2014-11-01100
Total number of active participants reported on line 7a of the Form 55002014-11-01157
Number of retired or separated participants receiving benefits2014-11-010
Number of other retired or separated participants entitled to future benefits2014-11-010
Total of all active and inactive participants2014-11-01157
Total participants, beginning-of-year2014-01-01130
Total number of active participants reported on line 7a of the Form 55002014-01-01131
Number of retired or separated participants receiving benefits2014-01-010
Number of other retired or separated participants entitled to future benefits2014-01-010
Total of all active and inactive participants2014-01-01131

Form 5500 Responses for REVIONICS, INC. HEALTH AND WELFARE PLAN

2021: REVIONICS, INC. HEALTH AND WELFARE PLAN 2021 form 5500 responses
2021-01-01Type of plan entitySingle employer plan
2021-01-01Plan funding arrangement – InsuranceYes
2021-01-01Plan funding arrangement – General assets of the sponsorYes
2021-01-01Plan benefit arrangement – InsuranceYes
2021-01-01Plan benefit arrangement – General assets of the sponsorYes
2020: REVIONICS, INC. HEALTH AND WELFARE PLAN 2020 form 5500 responses
2020-01-01Type of plan entitySingle employer plan
2020-01-01Plan funding arrangement – InsuranceYes
2020-01-01Plan funding arrangement – General assets of the sponsorYes
2020-01-01Plan benefit arrangement – InsuranceYes
2020-01-01Plan benefit arrangement – General assets of the sponsorYes
2019: REVIONICS, INC. HEALTH AND WELFARE PLAN 2019 form 5500 responses
2019-01-01Type of plan entitySingle employer plan
2019-01-01Plan funding arrangement – InsuranceYes
2019-01-01Plan funding arrangement – General assets of the sponsorYes
2019-01-01Plan benefit arrangement – InsuranceYes
2019-01-01Plan benefit arrangement – General assets of the sponsorYes
2018: REVIONICS, INC. HEALTH AND WELFARE PLAN 2018 form 5500 responses
2018-01-01Type of plan entitySingle employer plan
2018-01-01Plan funding arrangement – InsuranceYes
2018-01-01Plan funding arrangement – General assets of the sponsorYes
2018-01-01Plan benefit arrangement – InsuranceYes
2018-01-01Plan benefit arrangement – General assets of the sponsorYes
2017: REVIONICS, INC. HEALTH AND WELFARE PLAN 2017 form 5500 responses
2017-11-01Type of plan entitySingle employer plan
2017-11-01This return/report is a short plan year return/report (less than 12 months)Yes
2017-11-01Plan funding arrangement – InsuranceYes
2017-11-01Plan funding arrangement – General assets of the sponsorYes
2017-11-01Plan benefit arrangement – InsuranceYes
2017-11-01Plan benefit arrangement – General assets of the sponsorYes
2016: REVIONICS, INC. HEALTH AND WELFARE PLAN 2016 form 5500 responses
2016-11-01Type of plan entitySingle employer plan
2016-11-01Plan funding arrangement – InsuranceYes
2016-11-01Plan funding arrangement – General assets of the sponsorYes
2016-11-01Plan benefit arrangement – InsuranceYes
2016-11-01Plan benefit arrangement – General assets of the sponsorYes
2016-01-01Type of plan entitySingle employer plan
2016-01-01Submission has been amendedNo
2016-01-01This submission is the final filingNo
2016-01-01This return/report is a short plan year return/report (less than 12 months)Yes
2016-01-01Plan is a collectively bargained planNo
2016-01-01Plan funding arrangement – InsuranceYes
2016-01-01Plan funding arrangement – General assets of the sponsorYes
2016-01-01Plan benefit arrangement – InsuranceYes
2016-01-01Plan benefit arrangement – General assets of the sponsorYes
2015: REVIONICS, INC. HEALTH AND WELFARE PLAN 2015 form 5500 responses
2015-11-01Type of plan entitySingle employer plan
2015-11-01Submission has been amendedYes
2015-11-01This submission is the final filingNo
2015-11-01This return/report is a short plan year return/report (less than 12 months)Yes
2015-11-01Plan is a collectively bargained planNo
2015-11-01Plan funding arrangement – InsuranceYes
2015-11-01Plan funding arrangement – General assets of the sponsorYes
2015-11-01Plan benefit arrangement – InsuranceYes
2015-11-01Plan benefit arrangement – General assets of the sponsorYes
2015-01-01Type of plan entitySingle employer plan
2015-01-01Submission has been amendedNo
2015-01-01This submission is the final filingNo
2015-01-01This return/report is a short plan year return/report (less than 12 months)Yes
2015-01-01Plan is a collectively bargained planNo
2015-01-01Plan funding arrangement – InsuranceYes
2015-01-01Plan funding arrangement – General assets of the sponsorYes
2015-01-01Plan benefit arrangement – InsuranceYes
2015-01-01Plan benefit arrangement – General assets of the sponsorYes
2014: REVIONICS, INC. HEALTH AND WELFARE PLAN 2014 form 5500 responses
2014-11-01Type of plan entitySingle employer plan
2014-11-01First time form 5500 has been submittedYes
2014-11-01Submission has been amendedYes
2014-11-01This submission is the final filingNo
2014-11-01This return/report is a short plan year return/report (less than 12 months)No
2014-11-01Plan is a collectively bargained planNo
2014-11-01Plan funding arrangement – InsuranceYes
2014-11-01Plan funding arrangement – General assets of the sponsorYes
2014-11-01Plan benefit arrangement – InsuranceYes
2014-11-01Plan benefit arrangement – General assets of the sponsorYes
2014-01-01Type of plan entitySingle employer plan
2014-01-01First time form 5500 has been submittedYes
2014-01-01Submission has been amendedNo
2014-01-01This submission is the final filingNo
2014-01-01This return/report is a short plan year return/report (less than 12 months)No
2014-01-01Plan is a collectively bargained planNo
2014-01-01Plan funding arrangement – InsuranceYes
2014-01-01Plan benefit arrangement – InsuranceYes

Insurance Providers Used on plan

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberFLX969050
Policy instance 4
Insurance contract or identification numberFLX969050
Number of Individuals Covered95
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $1,982
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedEMPLOYEE ASSISTANCE PROGRAM,ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $263,540
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $0
Amount paid for insurance broker fees1717
Additional information about fees paid to insurance brokerOVERRIDE
Insurance broker organization code?3
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number30095158
Policy instance 3
Insurance contract or identification number30095158
Number of Individuals Covered81
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $873
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $14,528
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $873
Amount paid for insurance broker fees0
Insurance broker organization code?3
NATIONAL UNION (National Association of Insurance Commissioners NAIC id number: 19445 )
Policy contract numberGTP0009156299
Policy instance 2
Insurance contract or identification numberGTP0009156299
Number of Individuals Covered96
Insurance policy start date2021-01-01
Insurance policy end date2021-03-31
Total amount of commissions paid to insurance brokerUSD $101
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedBUSINESS TRAVEL ACCIDENT
Welfare Benefit Premiums Paid to CarrierUSD $675
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $101
Amount paid for insurance broker fees0
Insurance broker organization code?3
BLUE CROSS BLUE SHIELD OF GEORGIA INC. (G0386) (National Association of Insurance Commissioners NAIC id number: 96962 )
Policy contract numberL01475
Policy instance 1
Insurance contract or identification numberL01475
Number of Individuals Covered369
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $47,906
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,420,897
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $47,906
Amount paid for insurance broker fees0
Insurance broker organization code?3
BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )
Policy contract number285130
Policy instance 1
Insurance contract or identification number285130
Number of Individuals Covered269
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $16,092
Total amount of fees paid to insurance companyUSD $1,755
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,316,484
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $16,092
Amount paid for insurance broker fees1755
Additional information about fees paid to insurance brokerOTHER COMMISSIONS
Insurance broker organization code?3
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number669025
Policy instance 2
Insurance contract or identification number669025
Number of Individuals Covered5
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $1,041
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $26,257
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,041
Amount paid for insurance broker fees0
Insurance broker organization code?3
NATIONAL UNION (National Association of Insurance Commissioners NAIC id number: 19445 )
Policy contract numberGTP0009156299
Policy instance 3
Insurance contract or identification numberGTP0009156299
Number of Individuals Covered109
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $292
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedBUSINESS TRAVEL ACCIDENT
Welfare Benefit Premiums Paid to CarrierUSD $1,946
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $292
Amount paid for insurance broker fees0
Insurance broker organization code?3
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number30095158
Policy instance 4
Insurance contract or identification number30095158
Number of Individuals Covered105
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $994
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $16,867
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $994
Amount paid for insurance broker fees0
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLUG0ATPK
Policy instance 5
Insurance contract or identification numberGLUG0ATPK
Number of Individuals Covered121
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $8,252
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT,EMPLOYEE ASSISTANCE PROGRAM
Welfare Benefit Premiums Paid to CarrierUSD $121,966
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $0
Amount paid for insurance broker fees8252
Additional information about fees paid to insurance brokerOTHER COMEPNSATION
Insurance broker organization code?3
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number909248
Policy instance 1
Insurance contract or identification number909248
Number of Individuals Covered285
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,462,333
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number669025
Policy instance 2
Insurance contract or identification number669025
Number of Individuals Covered5
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $1,047
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $22,897
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,047
Insurance broker organization code?3
NATIONAL UNION (National Association of Insurance Commissioners NAIC id number: 19445 )
Policy contract numberGTP0009156299
Policy instance 3
Insurance contract or identification numberGTP0009156299
Number of Individuals Covered124
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $704
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedBUSINESS TRAVEL ACCIDENT
Welfare Benefit Premiums Paid to CarrierUSD $4,695
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $704
Insurance broker organization code?3
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number556463
Policy instance 4
Insurance contract or identification number556463
Number of Individuals Covered122
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $145,848
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 numberGLUG0ATPK
Policy instance 5
Insurance contract or identification numberGLUG0ATPK
Number of Individuals Covered127
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $5,178
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT,EMPLOYEE ASSISTANCE PROGRAM
Welfare Benefit Premiums Paid to CarrierUSD $120,183
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $0
Amount paid for insurance broker fees5178
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGVTL0ATPK
Policy instance 4
Insurance contract or identification numberGVTL0ATPK
Number of Individuals Covered129
Insurance policy start date2017-11-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $3,225
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT,EMPLOYEE ASSISTANCE PROGRAM
Welfare Benefit Premiums Paid to CarrierUSD $19,310
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $0
Amount paid for insurance broker fees3225
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
Insurance broker nameGALLAGHER BENEFIT SERVICES, INC.
NATIONAL UNION (National Association of Insurance Commissioners NAIC id number: 19445 )
Policy contract numberGTP0009150924
Policy instance 3
Insurance contract or identification numberGTP0009150924
Number of Individuals Covered129
Insurance policy start date2017-02-11
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedBUSINESS TRAVEL ACCIDENT
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number669025
Policy instance 2
Insurance contract or identification number669025
Number of Individuals Covered8
Insurance policy start date2017-06-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $805
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $18,029
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $805
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameGALLAGHER BENEFIT SERVICES, INC.
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number909248
Policy instance 1
Insurance contract or identification number909248
Number of Individuals Covered337
Insurance policy start date2017-11-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $137,697
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 numberGLUG0ATPK
Policy instance 4
Insurance contract or identification numberGLUG0ATPK
Number of Individuals Covered157
Insurance policy start date2015-11-01
Insurance policy end date2015-12-31
Total amount of commissions paid to insurance brokerUSD $4,949
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
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 CarrierUSD $31,938
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,949
Insurance broker organization code?3
Insurance broker nameUSI INSURANCE SERVICES, LLC
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract numberKM05922205
Policy instance 3
Insurance contract or identification numberKM05922205
Number of Individuals Covered620
Insurance policy start date2015-11-01
Insurance policy end date2015-12-31
Total amount of commissions paid to insurance brokerUSD $3,117
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $32,769
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,117
Insurance broker organization code?3
Insurance broker nameUSI INSURANCE SERVICES, LLC
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number869385
Policy instance 2
Insurance contract or identification number869385
Number of Individuals Covered310
Insurance policy start date2015-11-01
Insurance policy end date2015-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number669025
Policy instance 1
Insurance contract or identification number669025
Number of Individuals Covered264
Insurance policy start date2015-06-01
Insurance policy end date2015-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number869385
Policy instance 1
Insurance contract or identification number869385
Number of Individuals Covered310
Insurance policy start date2014-11-01
Insurance policy end date2015-10-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $64,734
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $1,342,889
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Amount paid for insurance broker fees59562
Additional information about fees paid to insurance brokerDIRECT COMPENSATION
Insurance broker organization code?3
Insurance broker nameANCO INSURANCE SERVICES CORPORATION
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract numberKM05922205
Policy instance 2
Insurance contract or identification numberKM05922205
Number of Individuals Covered606
Insurance policy start date2014-11-01
Insurance policy end date2015-10-31
Total amount of commissions paid to insurance brokerUSD $16,091
Total amount of fees paid to insurance companyUSD $764
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $176,633
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $16,091
Amount paid for insurance broker fees764
Additional information about fees paid to insurance brokerSUPPLEMENTAL COMPENSATION
Insurance broker organization code?3
Insurance broker nameUSI INSURANCE SERVICES, LLC
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLUG0ATPK
Policy instance 3
Insurance contract or identification numberGLUG0ATPK
Number of Individuals Covered157
Insurance policy start date2014-11-01
Insurance policy end date2015-10-31
Total amount of commissions paid to insurance brokerUSD $28,837
Total amount of fees paid to insurance companyUSD $994
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
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 CarrierUSD $185,526
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $28,837
Amount paid for insurance broker fees994
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
Insurance broker nameUSI INSURANCE SERVICES, LLC
WORKERS ASSISTANCE PROGRAM (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract numberCR006
Policy instance 4
Insurance contract or identification numberCR006
Number of Individuals Covered157
Insurance policy start date2014-11-01
Insurance policy end date2015-10-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedEMPLOYEE ASSISTANCE PROGRAM
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 CarrierUSD $3,190
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number669025
Policy instance 1
Insurance contract or identification number669025
Number of Individuals Covered20
Insurance policy start date2014-06-01
Insurance policy end date2015-05-31
Total amount of commissions paid to insurance brokerUSD $9,207
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $133,097
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,328
Insurance broker organization code?3
Insurance broker nameJOHN BYOUK
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract numberKM05922205
Policy instance 3
Insurance contract or identification numberKM05922205
Number of Individuals Covered606
Insurance policy start date2014-11-01
Insurance policy end date2015-10-31
Total amount of commissions paid to insurance brokerUSD $16,091
Total amount of fees paid to insurance companyUSD $764
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $176,633
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $16,091
Amount paid for insurance broker fees764
Additional information about fees paid to insurance brokerSUPPLEMENTAL COMPENSATION
Insurance broker organization code?3
Insurance broker nameUSI INSURANCE SERVICES, LLC
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number869385
Policy instance 2
Insurance contract or identification number869385
Number of Individuals Covered310
Insurance policy start date2014-11-01
Insurance policy end date2015-10-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $64,734
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $1,342,889
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Amount paid for insurance broker fees59562
Additional information about fees paid to insurance brokerDIRECT COMPENSATION
Insurance broker organization code?3
Insurance broker nameANCO INSURANCE SERVICES OF HOUSTON
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLUG0ATPK
Policy instance 4
Insurance contract or identification numberGLUG0ATPK
Number of Individuals Covered157
Insurance policy start date2014-11-01
Insurance policy end date2015-10-31
Total amount of commissions paid to insurance brokerUSD $28,837
Total amount of fees paid to insurance companyUSD $994
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
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 CarrierUSD $185,526
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $28,837
Amount paid for insurance broker fees994
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
Insurance broker nameUSI INSURANCE SERVICES, LLC
UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 )
Policy contract number5301864
Policy instance 5
Insurance contract or identification number5301864
Number of Individuals Covered127
Insurance policy start date2014-09-01
Insurance policy end date2014-10-31
Total amount of commissions paid to insurance brokerUSD $2,880
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
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 CarrierUSD $23,951
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,880
Insurance broker organization code?3
Insurance broker nameUSI INSURANCE SERVICES, INC.
HEALTH SMART (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number204438
Policy instance 3
Insurance contract or identification number204438
Number of Individuals Covered117
Insurance policy start date2014-01-01
Insurance policy end date2014-10-31
Total amount of commissions paid to insurance brokerUSD $1,705
Total amount of fees paid to insurance companyUSD $150
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $21,030
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $1,705
Amount paid for insurance broker fees150
Additional information about fees paid to insurance brokerADMINISTRATION FEES
Insurance broker organization code?3
Insurance broker nameUNKNOWN
UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 )
Policy contract number5301864
Policy instance 4
Insurance contract or identification number5301864
Number of Individuals Covered127
Insurance policy start date2013-09-01
Insurance policy end date2014-08-31
Total amount of commissions paid to insurance brokerUSD $9,653
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
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 CarrierUSD $124,247
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $9,098
Insurance broker organization code?3
Insurance broker nameANCO INSURANCE SERVICES CORPORATION
SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )
Policy contract number231507
Policy instance 2
Insurance contract or identification number231507
Number of Individuals Covered115
Insurance policy start date2014-09-01
Insurance policy end date2014-10-31
Total amount of commissions paid to insurance brokerUSD $899
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $13,259
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $899
Insurance broker organization code?3
Insurance broker nameUSI INSURANCE SERVICES, LLC
SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )
Policy contract number231507
Policy instance 1
Insurance contract or identification number231507
Number of Individuals Covered108
Insurance policy start date2013-09-01
Insurance policy end date2014-08-31
Total amount of commissions paid to insurance brokerUSD $7,886
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $113,043
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $7,197
Insurance broker organization code?3
Insurance broker nameUSI INSURANCE SERVICES, LLC

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