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THLOPTHLOCCO TRIBAL TOWN SEC 125 PREMIUM ONLY PLAN 401k Plan overview

Plan NameTHLOPTHLOCCO TRIBAL TOWN SEC 125 PREMIUM ONLY PLAN
Plan identification number 501

THLOPTHLOCCO TRIBAL TOWN SEC 125 PREMIUM ONLY PLAN Benefits

401k Plan TypeWelfare Benefit
Plan Features/Benefits
  • Health (other than dental or vision)
  • Life insurance
  • Dental
  • Vision
  • Temporary disability (accident and sickness)
  • Other welfare benefit cover

401k Sponsoring company profile

THLOPTHLOCCO TRIBAL TOWN has sponsored the creation of one or more 401k plans.

Company Name:THLOPTHLOCCO TRIBAL TOWN
Employer identification number (EIN):731023436
NAIC Classification:921000

Form 5500 Filing Information

Submission information for form 5500 for 401k plan THLOPTHLOCCO TRIBAL TOWN SEC 125 PREMIUM ONLY PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5012021-04-15KYLE MORROW2023-02-14
5012020-04-15RYAN MORROW2021-11-30
5012019-04-15
5012018-04-15RYAN MORROW2019-11-27
5012017-04-15RYAN MORROW
5012016-04-15RYAN MORROW
5012015-04-15
5012014-04-15RYAN MORROW
5012013-04-15MAX TRICKEY
5012012-04-15GEORGE SCOTT
5012011-04-15GEORGE SCOTT

Plan Statistics for THLOPTHLOCCO TRIBAL TOWN SEC 125 PREMIUM ONLY PLAN

401k plan membership statisitcs for THLOPTHLOCCO TRIBAL TOWN SEC 125 PREMIUM ONLY PLAN

Measure Date Value
2021: THLOPTHLOCCO TRIBAL TOWN SEC 125 PREMIUM ONLY PLAN 2021 401k membership
Total participants, beginning-of-year2021-04-15124
Total number of active participants reported on line 7a of the Form 55002021-04-15119
Total of all active and inactive participants2021-04-15119
Total participants2021-04-15119
2020: THLOPTHLOCCO TRIBAL TOWN SEC 125 PREMIUM ONLY PLAN 2020 401k membership
Total participants, beginning-of-year2020-04-15144
Total number of active participants reported on line 7a of the Form 55002020-04-15124
Total of all active and inactive participants2020-04-15124
Total participants2020-04-15124
2019: THLOPTHLOCCO TRIBAL TOWN SEC 125 PREMIUM ONLY PLAN 2019 401k membership
Total participants, beginning-of-year2019-04-15143
Total number of active participants reported on line 7a of the Form 55002019-04-15144
Total of all active and inactive participants2019-04-15144
Total participants2019-04-15144
2018: THLOPTHLOCCO TRIBAL TOWN SEC 125 PREMIUM ONLY PLAN 2018 401k membership
Total participants, beginning-of-year2018-04-15110
Total number of active participants reported on line 7a of the Form 55002018-04-15143
Total of all active and inactive participants2018-04-15143
Total participants2018-04-15143
2017: THLOPTHLOCCO TRIBAL TOWN SEC 125 PREMIUM ONLY PLAN 2017 401k membership
Total participants, beginning-of-year2017-04-15115
Total number of active participants reported on line 7a of the Form 55002017-04-15110
Total of all active and inactive participants2017-04-15110
Total participants2017-04-15110
2016: THLOPTHLOCCO TRIBAL TOWN SEC 125 PREMIUM ONLY PLAN 2016 401k membership
Total participants, beginning-of-year2016-04-15111
Total number of active participants reported on line 7a of the Form 55002016-04-15115
Total of all active and inactive participants2016-04-15115
Total participants2016-04-15115
2015: THLOPTHLOCCO TRIBAL TOWN SEC 125 PREMIUM ONLY PLAN 2015 401k membership
Total participants, beginning-of-year2015-04-15123
Total number of active participants reported on line 7a of the Form 55002015-04-15111
Number of retired or separated participants receiving benefits2015-04-150
Number of other retired or separated participants entitled to future benefits2015-04-150
Total of all active and inactive participants2015-04-15111
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits2015-04-150
Total participants2015-04-15111
2014: THLOPTHLOCCO TRIBAL TOWN SEC 125 PREMIUM ONLY PLAN 2014 401k membership
Total participants, beginning-of-year2014-04-15114
Total number of active participants reported on line 7a of the Form 55002014-04-15123
Number of retired or separated participants receiving benefits2014-04-150
Number of other retired or separated participants entitled to future benefits2014-04-150
Total of all active and inactive participants2014-04-15123
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits2014-04-150
Total participants2014-04-15123
2013: THLOPTHLOCCO TRIBAL TOWN SEC 125 PREMIUM ONLY PLAN 2013 401k membership
Total participants, beginning-of-year2013-04-15103
Total number of active participants reported on line 7a of the Form 55002013-04-15114
Number of retired or separated participants receiving benefits2013-04-150
Number of other retired or separated participants entitled to future benefits2013-04-150
Total of all active and inactive participants2013-04-15114
Total participants2013-04-15114
2012: THLOPTHLOCCO TRIBAL TOWN SEC 125 PREMIUM ONLY PLAN 2012 401k membership
Total participants, beginning-of-year2012-04-15115
Total number of active participants reported on line 7a of the Form 55002012-04-15102
Number of retired or separated participants receiving benefits2012-04-151
Total of all active and inactive participants2012-04-15103
Total participants2012-04-15103
2011: THLOPTHLOCCO TRIBAL TOWN SEC 125 PREMIUM ONLY PLAN 2011 401k membership
Total participants, beginning-of-year2011-04-15151
Total number of active participants reported on line 7a of the Form 55002011-04-15115
Total of all active and inactive participants2011-04-15115
Total participants2011-04-15115

Financial Data on THLOPTHLOCCO TRIBAL TOWN SEC 125 PREMIUM ONLY PLAN

Measure Date Value
2021 : THLOPTHLOCCO TRIBAL TOWN SEC 125 PREMIUM ONLY PLAN 2021 401k financial data
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year2021-04-14No
Was this plan covered by a fidelity bond2021-04-14No
Were there any nonexempt tranactions with any party-in-interest2021-04-14No
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser2021-04-14No
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)2021-04-14No
Were any loans by the plan or fixed income obligations due to the plan in default2021-04-14No
Were any leases to which the plan was party in default or uncollectible2021-04-14No
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets2021-04-14No
Was there a failure to transmit to the plan any participant contributions2021-04-14No
Has the plan failed to provide any benefit when due under the plan2021-04-14No
Did the plan have assets held for investment2021-04-14No
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser2021-04-14No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC2021-04-14No

Form 5500 Responses for THLOPTHLOCCO TRIBAL TOWN SEC 125 PREMIUM ONLY PLAN

2021: THLOPTHLOCCO TRIBAL TOWN SEC 125 PREMIUM ONLY PLAN 2021 form 5500 responses
2021-04-15Type of plan entitySingle employer plan
2021-04-15Plan funding arrangement – InsuranceYes
2021-04-15Plan benefit arrangement – InsuranceYes
2020: THLOPTHLOCCO TRIBAL TOWN SEC 125 PREMIUM ONLY PLAN 2020 form 5500 responses
2020-04-15Type of plan entitySingle employer plan
2020-04-15Plan funding arrangement – InsuranceYes
2020-04-15Plan funding arrangement – General assets of the sponsorYes
2020-04-15Plan benefit arrangement – InsuranceYes
2020-04-15Plan benefit arrangement – General assets of the sponsorYes
2019: THLOPTHLOCCO TRIBAL TOWN SEC 125 PREMIUM ONLY PLAN 2019 form 5500 responses
2019-04-15Type of plan entitySingle employer plan
2019-04-15Plan funding arrangement – InsuranceYes
2019-04-15Plan benefit arrangement – InsuranceYes
2018: THLOPTHLOCCO TRIBAL TOWN SEC 125 PREMIUM ONLY PLAN 2018 form 5500 responses
2018-04-15Type of plan entitySingle employer plan
2018-04-15Plan funding arrangement – InsuranceYes
2018-04-15Plan benefit arrangement – InsuranceYes
2017: THLOPTHLOCCO TRIBAL TOWN SEC 125 PREMIUM ONLY PLAN 2017 form 5500 responses
2017-04-15Type of plan entitySingle employer plan
2017-04-15Plan funding arrangement – InsuranceYes
2017-04-15Plan benefit arrangement – InsuranceYes
2016: THLOPTHLOCCO TRIBAL TOWN SEC 125 PREMIUM ONLY PLAN 2016 form 5500 responses
2016-04-15Type of plan entitySingle employer plan
2016-04-15Plan funding arrangement – InsuranceYes
2016-04-15Plan benefit arrangement – InsuranceYes
2015: THLOPTHLOCCO TRIBAL TOWN SEC 125 PREMIUM ONLY PLAN 2015 form 5500 responses
2015-04-15Type of plan entitySingle employer plan
2015-04-15Plan funding arrangement – InsuranceYes
2015-04-15Plan benefit arrangement – InsuranceYes
2014: THLOPTHLOCCO TRIBAL TOWN SEC 125 PREMIUM ONLY PLAN 2014 form 5500 responses
2014-04-15Type of plan entitySingle employer plan
2014-04-15Plan funding arrangement – InsuranceYes
2014-04-15Plan benefit arrangement – InsuranceYes
2013: THLOPTHLOCCO TRIBAL TOWN SEC 125 PREMIUM ONLY PLAN 2013 form 5500 responses
2013-04-15Type of plan entitySingle employer plan
2013-04-15Plan funding arrangement – InsuranceYes
2013-04-15Plan benefit arrangement – InsuranceYes
2012: THLOPTHLOCCO TRIBAL TOWN SEC 125 PREMIUM ONLY PLAN 2012 form 5500 responses
2012-04-15Type of plan entityMulitple employer plan
2012-04-15Plan funding arrangement – InsuranceYes
2012-04-15Plan benefit arrangement – InsuranceYes
2011: THLOPTHLOCCO TRIBAL TOWN SEC 125 PREMIUM ONLY PLAN 2011 form 5500 responses
2011-04-15Type of plan entityMulitple employer plan
2011-04-15Plan funding arrangement – InsuranceYes
2011-04-15Plan benefit arrangement – InsuranceYes

Insurance Providers Used on plan

SYMETRA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68608 )
Policy contract number12356000
Policy instance 7
Insurance contract or identification number12356000
Number of Individuals Covered73
Insurance policy start date2022-04-01
Insurance policy end date2023-03-31
Total amount of commissions paid to insurance brokerUSD $8,126
Total amount of fees paid to insurance companyUSD $263
Other welfare benefits providedCRITIAL ILLNESS, ACCIDENT
Welfare Benefit Premiums Paid to CarrierUSD $46,749
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $8,126
Insurance broker organization code?3
Amount paid for insurance broker fees263
Additional information about fees paid to insurance brokerGROUP SUPPLEMENTAL COMMISSION
BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )
Policy contract number253570
Policy instance 1
Insurance contract or identification number253570
Number of Individuals Covered140
Insurance policy start date2022-04-01
Insurance policy end date2023-03-31
Total amount of commissions paid to insurance brokerUSD $37,043
Total amount of fees paid to insurance companyUSD $3,207
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $634,787
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Amount paid for insurance broker fees1737
Additional information about fees paid to insurance brokerBONUSES
Insurance broker organization code?3
Commission paid to Insurance BrokerUSD $37,043
LIBERTY NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65331 )
Policy contract number81018
Policy instance 2
Insurance contract or identification number81018
Number of Individuals Covered11
Insurance policy start date2022-05-01
Insurance policy end date2023-04-30
Total amount of commissions paid to insurance brokerUSD $324
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $4,733
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $98
Insurance broker organization code?3
AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )
Policy contract numberBMW11
Policy instance 3
Insurance contract or identification numberBMW11
Number of Individuals Covered14
Insurance policy start date2022-04-01
Insurance policy end date2023-03-31
Total amount of commissions paid to insurance brokerUSD $4,422
Life Insurance Welfare BenefitYes
Other welfare benefits providedAD&D, CANCER, SPECIAL EVENT
Welfare Benefit Premiums Paid to CarrierUSD $20,873
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,879
Insurance broker organization code?3
Additional information about fees paid to insurance brokerADMIN FEES
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract numberE4322806
Policy instance 4
Insurance contract or identification numberE4322806
Number of Individuals Covered1
Insurance policy start date2022-10-01
Insurance policy end date2023-09-30
Total amount of commissions paid to insurance brokerUSD $4
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $512
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4
Insurance broker organization code?3
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number30103730
Policy instance 5
Insurance contract or identification number30103730
Number of Individuals Covered100
Insurance policy start date2022-04-01
Insurance policy end date2023-05-31
Total amount of commissions paid to insurance brokerUSD $1,044
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $13,271
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $-29
Insurance broker organization code?3
SYMETRA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68608 )
Policy contract number01-018228-00
Policy instance 6
Insurance contract or identification number01-018228-00
Number of Individuals Covered100
Insurance policy start date2022-04-01
Insurance policy end date2023-03-31
Total amount of commissions paid to insurance brokerUSD $5,497
Total amount of fees paid to insurance companyUSD $-31
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $36,650
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Amount paid for insurance broker fees-31
Additional information about fees paid to insurance brokerGROUP SUPPLEMENTAL COMMISSIONS
Insurance broker organization code?3
Commission paid to Insurance BrokerUSD $-120
BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )
Policy contract number253570
Policy instance 1
Insurance contract or identification number253570
Number of Individuals Covered119
Insurance policy start date2021-04-01
Insurance policy end date2022-03-30
Total amount of commissions paid to insurance brokerUSD $37,657
Total amount of fees paid to insurance companyUSD $1,777
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $651,947
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $37,657
Amount paid for insurance broker fees1777
Additional information about fees paid to insurance brokerBONUSES
Insurance broker organization code?3
LIBERTY NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65331 )
Policy contract number81018
Policy instance 2
Insurance contract or identification number81018
Number of Individuals Covered9
Insurance policy start date2022-01-01
Insurance policy end date2022-11-30
Total amount of commissions paid to insurance brokerUSD $594
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $4,295
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $155
Insurance broker organization code?3
AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )
Policy contract numberBMW11
Policy instance 3
Insurance contract or identification numberBMW11
Number of Individuals Covered15
Insurance policy start date2021-04-01
Insurance policy end date2022-03-31
Total amount of commissions paid to insurance brokerUSD $2,083
Total amount of fees paid to insurance companyUSD $32
Life Insurance Welfare BenefitYes
Other welfare benefits providedAD&D, CANCER, SPECIAL EVENT
Welfare Benefit Premiums Paid to CarrierUSD $14,669
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,262
Amount paid for insurance broker fees22
Additional information about fees paid to insurance brokerADMIN FEES
Insurance broker organization code?3
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract numberE4322806
Policy instance 4
Insurance contract or identification numberE4322806
Number of Individuals Covered1
Insurance policy start date2021-10-01
Insurance policy end date2022-09-30
Total amount of commissions paid to insurance brokerUSD $4
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $438
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4
Insurance broker organization code?3
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number30103730
Policy instance 5
Insurance contract or identification number30103730
Number of Individuals Covered96
Insurance policy start date2021-04-01
Insurance policy end date2022-03-31
Total amount of commissions paid to insurance brokerUSD $1,180
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $10,835
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $712
Insurance broker organization code?3
SYMETRA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68608 )
Policy contract number01-018228-00
Policy instance 6
Insurance contract or identification number01-018228-00
Number of Individuals Covered100
Insurance policy start date2021-04-01
Insurance policy end date2022-03-31
Total amount of commissions paid to insurance brokerUSD $7,089
Total amount of fees paid to insurance companyUSD $947
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $42,173
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Amount paid for insurance broker fees947
Additional information about fees paid to insurance brokerGROUP SUPPLEMENTAL COMMISSIONS
Insurance broker organization code?3
Commission paid to Insurance BrokerUSD $7,089
BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )
Policy contract number253570
Policy instance 1
Insurance contract or identification number253570
Number of Individuals Covered124
Insurance policy start date2020-04-01
Insurance policy end date2021-03-31
Total amount of commissions paid to insurance brokerUSD $34,785
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $620,864
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $34,785
Insurance broker organization code?3
LIBERTY NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65331 )
Policy contract number
Policy instance 2
Life Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Insurance broker organization code?3
AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )
Policy contract numberBMW11
Policy instance 3
Insurance contract or identification numberBMW11
Number of Individuals Covered16
Insurance policy start date2020-04-01
Insurance policy end date2021-03-31
Total amount of commissions paid to insurance brokerUSD $2,583
Total amount of fees paid to insurance companyUSD $79
Life Insurance Welfare BenefitYes
Other welfare benefits providedAD&D, CANCER, SPECIAL EVENT
Welfare Benefit Premiums Paid to CarrierUSD $18,256
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,528
Amount paid for insurance broker fees56
Additional information about fees paid to insurance brokerADMIN FEES
Insurance broker organization code?3
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract numberE4322806
Policy instance 4
Insurance contract or identification numberE4322806
Life Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Insurance broker organization code?3
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number0158104
Policy instance 5
Insurance contract or identification number0158104
Number of Individuals Covered142
Insurance policy start date2020-04-01
Insurance policy end date2021-03-31
Total amount of commissions paid to insurance brokerUSD $930
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $10,185
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $930
Insurance broker organization code?3
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number0914298
Policy instance 1
Insurance contract or identification number0914298
Number of Individuals Covered144
Insurance policy start date2019-04-01
Insurance policy end date2020-03-31
Total amount of commissions paid to insurance brokerUSD $4,137
Total amount of fees paid to insurance companyUSD $30,856
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $412,805
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,137
Amount paid for insurance broker fees30856
Additional information about fees paid to insurance brokerSERVICE FEE AGREEMENT
Insurance broker organization code?3
LIBERTY NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65331 )
Policy contract number
Policy instance 2
Number of Individuals Covered11
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $672
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $4,991
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $184
Insurance broker organization code?3
AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )
Policy contract numberBMW11
Policy instance 3
Insurance contract or identification numberBMW11
Number of Individuals Covered20
Insurance policy start date2019-04-01
Insurance policy end date2020-03-31
Total amount of commissions paid to insurance brokerUSD $2,994
Total amount of fees paid to insurance companyUSD $160
Life Insurance Welfare BenefitYes
Other welfare benefits providedAD&D, CANCER, SPECIAL EVENT
Welfare Benefit Premiums Paid to CarrierUSD $19,433
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,633
Amount paid for insurance broker fees68
Additional information about fees paid to insurance brokerADMIN FEES
Insurance broker organization code?3
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract numberE4322806
Policy instance 4
Insurance contract or identification numberE4322806
Number of Individuals Covered1
Insurance policy start date2019-04-01
Insurance policy end date2020-03-31
Total amount of commissions paid to insurance brokerUSD $3
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $477
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3
Insurance broker organization code?3
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number30032617
Policy instance 5
Insurance contract or identification number30032617
Number of Individuals Covered98
Insurance policy start date2019-04-01
Insurance policy end date2020-03-31
Total amount of commissions paid to insurance brokerUSD $899
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $14,144
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
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number0914298
Policy instance 2
Insurance contract or identification number0914298
Number of Individuals Covered143
Insurance policy start date2018-04-01
Insurance policy end date2019-03-31
Total amount of commissions paid to insurance brokerUSD $4,712
Total amount of fees paid to insurance companyUSD $30,907
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $634,706
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,712
Amount paid for insurance broker fees30907
Additional information about fees paid to insurance brokerSERVICE FEE AGREEMENT
Insurance broker organization code?3
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number30032617
Policy instance 7
Insurance contract or identification number30032617
Number of Individuals Covered36
Insurance policy start date2018-04-01
Insurance policy end date2019-03-31
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $5,525
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number30032617
Policy instance 6
Insurance contract or identification number30032617
Number of Individuals Covered65
Insurance policy start date2018-04-01
Insurance policy end date2019-03-31
Total amount of commissions paid to insurance brokerUSD $893
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $8,491
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $893
Insurance broker organization code?3
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract numberE4322806
Policy instance 5
Insurance contract or identification numberE4322806
Number of Individuals Covered1
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $23
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $523
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $19
Insurance broker organization code?3
AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )
Policy contract numberBMW11
Policy instance 4
Insurance contract or identification numberBMW11
Number of Individuals Covered20
Insurance policy start date2018-04-01
Insurance policy end date2019-03-31
Total amount of commissions paid to insurance brokerUSD $3,174
Total amount of fees paid to insurance companyUSD $310
Life Insurance Welfare BenefitYes
Other welfare benefits providedAD&D, CANCER, SPECIAL EVENT
Welfare Benefit Premiums Paid to CarrierUSD $20,257
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,919
Amount paid for insurance broker fees222
Additional information about fees paid to insurance brokerADMIN FEES
Insurance broker organization code?3
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number305046
Policy instance 1
Insurance contract or identification number305046
Number of Individuals Covered102
Insurance policy start date2018-04-01
Insurance policy end date2019-03-31
Total amount of commissions paid to insurance brokerUSD $8,982
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedCRITICAL ILLNESS
Welfare Benefit Premiums Paid to CarrierUSD $66,486
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $8,982
Insurance broker organization code?3
LIBERTY NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65331 )
Policy contract number
Policy instance 3
Number of Individuals Covered11
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $761
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $6,262
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $210
Insurance broker organization code?3
BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )
Policy contract number191526
Policy instance 5
Insurance contract or identification number191526
Number of Individuals Covered112
Insurance policy start date2017-04-01
Insurance policy end date2018-03-31
Total amount of commissions paid to insurance brokerUSD $37,920
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $676,358
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $37,920
Insurance broker organization code?3
Insurance broker nameGALLAGHER BENEFIT SERVICES
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberCI 960445
Policy instance 4
Insurance contract or identification numberCI 960445
Number of Individuals Covered71
Insurance policy start date2017-05-01
Insurance policy end date2018-04-30
Total amount of commissions paid to insurance brokerUSD $4,392
Temporary Disability Insurance Welfare BenefitYes
Other welfare benefits providedCRITICAL ILLNESS
Welfare Benefit Premiums Paid to CarrierUSD $12,403
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,392
Insurance broker organization code?3
Insurance broker nameGALLAGHER BENEFIT SERVICE
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number305046
Policy instance 3
Insurance contract or identification number305046
Number of Individuals Covered110
Insurance policy start date2017-04-01
Insurance policy end date2018-03-31
Total amount of commissions paid to insurance brokerUSD $6,129
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $48,748
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6,129
Insurance broker organization code?3
Insurance broker nameGALLAGHER BENEFIT SERVICES INC
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number30032617
Policy instance 2
Insurance contract or identification number30032617
Number of Individuals Covered98
Insurance policy start date2017-04-01
Insurance policy end date2018-03-31
Total amount of commissions paid to insurance brokerUSD $890
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $13,927
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $779
Insurance broker organization code?3
Insurance broker nameGALLAGHER BENEFIT SERVICES
AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )
Policy contract numberBMW11
Policy instance 1
Insurance contract or identification numberBMW11
Number of Individuals Covered23
Insurance policy start date2017-04-01
Insurance policy end date2018-03-31
Total amount of commissions paid to insurance brokerUSD $6,175
Total amount of fees paid to insurance companyUSD $463
Life Insurance Welfare BenefitYes
Other welfare benefits providedAD&D, CANCER, SPECIAL EVENT
Welfare Benefit Premiums Paid to CarrierUSD $26,062
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,050
Amount paid for insurance broker fees331
Additional information about fees paid to insurance brokerADMIN FEES
Insurance broker organization code?3
Insurance broker nameJARRELL PRENTICE
STATE FARM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69108 )
Policy contract numberB04-2404-5942
Policy instance 2
Insurance contract or identification numberB04-2404-5942
Number of Individuals Covered111
Insurance policy start date2015-05-01
Insurance policy end date2016-04-30
Total amount of commissions paid to insurance brokerUSD $437
Life Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $437
Insurance broker organization code?3
Insurance broker nameMATT MCCOY
DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 )
Policy contract number4094-00
Policy instance 3
Insurance contract or identification number4094-00
Number of Individuals Covered29
Insurance policy start date2015-01-01
Insurance policy end date2015-12-31
Total amount of commissions paid to insurance brokerUSD $733
Temporary Disability Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $6,009
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $733
Insurance broker organization code?3
Insurance broker nameSCOTT MCCOY INSURANCE AGENCY INC
DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 )
Policy contract number4094-01
Policy instance 4
Insurance contract or identification number4094-01
Number of Individuals Covered75
Insurance policy start date2015-01-01
Insurance policy end date2015-12-31
Total amount of commissions paid to insurance brokerUSD $1,548
Temporary Disability Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $10,655
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,548
Insurance broker organization code?3
Insurance broker nameSCOTT MCCOY INSURANCE AGENCY INC
AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )
Policy contract numberBMW11
Policy instance 5
Insurance contract or identification numberBMW11
Number of Individuals Covered21
Insurance policy start date2015-04-01
Insurance policy end date2016-03-31
Total amount of commissions paid to insurance brokerUSD $2,594
Total amount of fees paid to insurance companyUSD $160
Life Insurance Welfare BenefitYes
Other welfare benefits providedAD&D, CANCER, SPECIAL EVENT
Welfare Benefit Premiums Paid to CarrierUSD $11,547
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,702
Amount paid for insurance broker fees76
Additional information about fees paid to insurance brokerADMIN
Insurance broker organization code?3
Insurance broker nameMICHAEL ARTHUR KIRK
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 95478 )
Policy contract number30032617
Policy instance 6
Insurance contract or identification number30032617
Number of Individuals Covered93
Insurance policy start date2015-04-01
Insurance policy end date2016-03-31
Total amount of commissions paid to insurance brokerUSD $727
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $9,538
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $727
Insurance broker organization code?3
Insurance broker nameSCOTT MCCOY INSURANCE AGENCY, INC.
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number0869466
Policy instance 7
Insurance contract or identification number0869466
Number of Individuals Covered143
Insurance policy start date2015-04-01
Insurance policy end date2016-03-31
Total amount of commissions paid to insurance brokerUSD $3,330
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $36,271
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,330
Insurance broker organization code?3
Insurance broker nameSCOTT MCCOY INS
TRUSTMARK LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62863 )
Policy contract numberSM86504E
Policy instance 1
Insurance contract or identification numberSM86504E
Number of Individuals Covered92
Insurance policy start date2015-04-01
Insurance policy end date2016-04-01
Total amount of commissions paid to insurance brokerUSD $19,414
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $129,424
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $19,414
Insurance broker organization code?3
Insurance broker nameSCOTT MCCOY INS
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 95478 )
Policy contract number30032617
Policy instance 6
Insurance contract or identification number30032617
Number of Individuals Covered75
Insurance policy start date2014-04-01
Insurance policy end date2015-03-31
Total amount of commissions paid to insurance brokerUSD $655
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $8,105
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $655
Insurance broker organization code?3
Insurance broker nameSCOTT MCCOY INSURANCE AGENCY, INC.
AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )
Policy contract numberBMW11
Policy instance 5
Insurance contract or identification numberBMW11
Number of Individuals Covered12
Insurance policy start date2014-04-01
Insurance policy end date2015-03-31
Total amount of commissions paid to insurance brokerUSD $2,229
Total amount of fees paid to insurance companyUSD $73
Life Insurance Welfare BenefitYes
Other welfare benefits providedAD&D, CANCER, SPECIAL EVENT
Welfare Benefit Premiums Paid to CarrierUSD $7,819
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,119
Amount paid for insurance broker fees30
Additional information about fees paid to insurance brokerADMIN
Insurance broker organization code?3
Insurance broker nameMICHAEL KIRK
DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 )
Policy contract number4094-01
Policy instance 4
Insurance contract or identification number4094-01
Number of Individuals Covered72
Insurance policy start date2014-01-01
Insurance policy end date2014-12-31
Total amount of commissions paid to insurance brokerUSD $1,676
Temporary Disability Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $11,127
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,676
Insurance broker organization code?3
Insurance broker nameSCOTT MCCOY INSURANCE AGENCY INC
DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 )
Policy contract number4094-00
Policy instance 3
Insurance contract or identification number4094-00
Number of Individuals Covered36
Insurance policy start date2014-01-01
Insurance policy end date2014-12-31
Total amount of commissions paid to insurance brokerUSD $846
Temporary Disability Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $6,435
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3
Insurance broker organization code?3
Insurance broker nameSCOTT MCCOY INSURANCE AGENCY INC
STATE FARM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69108 )
Policy contract numberB04-2404-5942
Policy instance 2
Insurance contract or identification numberB04-2404-5942
Number of Individuals Covered101
Insurance policy start date2014-05-01
Insurance policy end date2015-04-30
Total amount of commissions paid to insurance brokerUSD $424
Life Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $424
Insurance broker organization code?3
Insurance broker nameMATT MCCOY
BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )
Policy contract numberY08981
Policy instance 1
Insurance contract or identification numberY08981
Number of Individuals Covered67
Insurance policy start date2014-04-01
Insurance policy end date2015-03-31
Total amount of commissions paid to insurance brokerUSD $20,488
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $377,628
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $20,488
Insurance broker organization code?3
Insurance broker nameSCOTT MCCOY INS
DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 )
Policy contract number4094-00
Policy instance 3
Insurance contract or identification number4094-00
Number of Individuals Covered37
Insurance policy start date2013-01-01
Insurance policy end date2013-12-31
Total amount of commissions paid to insurance brokerUSD $788
Temporary Disability Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $6,765
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $246
Insurance broker organization code?3
Insurance broker nameSCOTT MCCOY INSURANCE AGENCY INC
BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )
Policy contract numberY08981
Policy instance 1
Insurance contract or identification numberY08981
Number of Individuals Covered54
Insurance policy start date2013-04-01
Insurance policy end date2014-03-31
Total amount of commissions paid to insurance brokerUSD $14,962
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $281,123
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $14,962
Insurance broker organization code?3
Insurance broker nameSCOTT MCCOY INS
DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 )
Policy contract number4094-01
Policy instance 4
Insurance contract or identification number4094-01
Number of Individuals Covered70
Insurance policy start date2013-01-01
Insurance policy end date2013-12-31
Total amount of commissions paid to insurance brokerUSD $1,441
Temporary Disability Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $10,980
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $320
Insurance broker organization code?3
Insurance broker nameSCOTT MCCOY INSURANCE AGENCY INC
AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )
Policy contract numberBQU08
Policy instance 5
Insurance contract or identification numberBQU08
Number of Individuals Covered19
Insurance policy start date2013-04-01
Insurance policy end date2014-03-31
Total amount of commissions paid to insurance brokerUSD $5,004
Life Insurance Welfare BenefitYes
Other welfare benefits providedAD&D, CANCER, SPECIAL EVENT
Welfare Benefit Premiums Paid to CarrierUSD $15,811
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,650
Insurance broker organization code?3
Insurance broker nameTRAVIS D HURT
AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )
Policy contract numberBMW11
Policy instance 6
Insurance contract or identification numberBMW11
Number of Individuals Covered10
Insurance policy start date2013-06-01
Insurance policy end date2014-03-31
Total amount of commissions paid to insurance brokerUSD $1,260
Life Insurance Welfare BenefitYes
Other welfare benefits providedAD&D, CANCER, SPECIAL EVENT
Welfare Benefit Premiums Paid to CarrierUSD $6,743
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $719
Insurance broker organization code?3
Insurance broker nameJOHN A WILLIAMS COMPANY INC
STATE FARM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69108 )
Policy contract numberB04-2404-5942
Policy instance 2
Insurance contract or identification numberB04-2404-5942
Number of Individuals Covered103
Insurance policy start date2013-05-01
Insurance policy end date2014-04-30
Total amount of commissions paid to insurance brokerUSD $420
Life Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $420
Insurance broker organization code?3
Insurance broker nameMATT MCCOY
AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )
Policy contract numberBQU08
Policy instance 5
Insurance contract or identification numberBQU08
Insurance policy start date2012-04-01
Insurance policy end date2012-07-31
Total amount of commissions paid to insurance brokerUSD $1,624
Life Insurance Welfare BenefitYes
Other welfare benefits providedAD&D, CANCER, SPECIAL EVENT
Welfare Benefit Premiums Paid to CarrierUSD $3,683
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,178
Insurance broker organization code?3
Insurance broker nameTRAVIS D HURT
DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 )
Policy contract number4094-01
Policy instance 4
Insurance contract or identification number4094-01
Number of Individuals Covered68
Insurance policy start date2012-01-01
Insurance policy end date2012-12-31
Total amount of commissions paid to insurance brokerUSD $1,534
Temporary Disability Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $12,011
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,534
Insurance broker organization code?3
Insurance broker nameBANCFIRST INSURANCE SERVICES INC
DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 )
Policy contract number4094-00
Policy instance 3
Insurance contract or identification number4094-00
Number of Individuals Covered34
Insurance policy start date2012-01-01
Insurance policy end date2012-12-31
Total amount of commissions paid to insurance brokerUSD $728
Temporary Disability Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $6,871
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $728
Insurance broker organization code?3
Insurance broker nameBANCFIRST INSURANCE SERVICES INC
STATE FARM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69108 )
Policy contract numberB04-2404-5942
Policy instance 2
Insurance contract or identification numberB04-2404-5942
Number of Individuals Covered98
Insurance policy start date2012-05-01
Insurance policy end date2013-04-30
Total amount of commissions paid to insurance brokerUSD $412
Life Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $412
Insurance broker organization code?3
Insurance broker nameMATT MCCOY
AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )
Policy contract numberBMW11
Policy instance 6
Insurance contract or identification numberBMW11
Number of Individuals Covered16
Insurance policy start date2012-04-01
Insurance policy end date2012-07-31
Total amount of commissions paid to insurance brokerUSD $1,268
Total amount of fees paid to insurance companyUSD $140
Life Insurance Welfare BenefitYes
Other welfare benefits providedAD&D, CANCER, SPECIAL EVENT
Welfare Benefit Premiums Paid to CarrierUSD $3,349
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $900
Amount paid for insurance broker fees88
Additional information about fees paid to insurance brokerOTHER FEES
Insurance broker organization code?3
Insurance broker nameTRAVIS D HURT
BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )
Policy contract numberY08981
Policy instance 1
Insurance contract or identification numberY08981
Number of Individuals Covered86
Insurance policy start date2012-04-01
Insurance policy end date2013-03-31
Total amount of commissions paid to insurance brokerUSD $26,738
Total amount of fees paid to insurance companyUSD $800
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $251,902
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $26,738
Amount paid for insurance broker fees800
Additional information about fees paid to insurance brokerSPECIAL PROGRAMS
Insurance broker organization code?3
Insurance broker nameBANCFIRST INSURANCE SERVICES INC
AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )
Policy contract numberBMW11
Policy instance 6
Insurance contract or identification numberBMW11
Number of Individuals Covered14
Insurance policy start date2011-04-01
Insurance policy end date2012-03-31
Total amount of commissions paid to insurance brokerUSD $1,498
Life Insurance Welfare BenefitYes
Other welfare benefits providedAD&D, CANCER, SPECIAL EVENT
Welfare Benefit Premiums Paid to CarrierUSD $5,532
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )
Policy contract numberBQU08
Policy instance 5
Insurance contract or identification numberBQU08
Number of Individuals Covered22
Insurance policy start date2011-04-01
Insurance policy end date2012-03-31
Total amount of commissions paid to insurance brokerUSD $2,884
Total amount of fees paid to insurance companyUSD $41
Life Insurance Welfare BenefitYes
Other welfare benefits providedAD&D, CANCER, SPECIAL EVENT
Welfare Benefit Premiums Paid to CarrierUSD $10,900
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 )
Policy contract number4094-01
Policy instance 4
Insurance contract or identification number4094-01
Number of Individuals Covered90
Insurance policy start date2011-01-01
Insurance policy end date2011-12-31
Total amount of commissions paid to insurance brokerUSD $155
Temporary Disability Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $13,256
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 )
Policy contract number4094-00
Policy instance 3
Insurance contract or identification number4094-00
Number of Individuals Covered38
Insurance policy start date2011-01-01
Insurance policy end date2011-12-31
Total amount of commissions paid to insurance brokerUSD $59
Temporary Disability Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $6,485
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
STATE FARM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69108 )
Policy contract numberB04-2404-5942
Policy instance 2
Insurance contract or identification numberB04-2404-5942
Number of Individuals Covered113
Insurance policy start date2011-05-01
Insurance policy end date2012-04-30
Total amount of commissions paid to insurance brokerUSD $419
Life Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )
Policy contract numberY08981
Policy instance 1
Insurance contract or identification numberY08981
Number of Individuals Covered46
Insurance policy start date2011-04-01
Insurance policy end date2012-03-31
Total amount of commissions paid to insurance brokerUSD $5,085
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $270,583
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No

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