GRAND LAKE MENTAL HEALTH CENTER, INC. has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan GRAND LAKE MENTAL HEALTH CENTER, INC. WELFARE BENEFIT PLAN
401k plan membership statisitcs for GRAND LAKE MENTAL HEALTH CENTER, INC. WELFARE BENEFIT PLAN
| Measure | Date | Value |
|---|
| 2022: GRAND LAKE MENTAL HEALTH CENTER, INC. WELFARE BENEFIT PLAN 2022 401k membership |
|---|
| Total participants, beginning-of-year | 2022-03-01 | 1,165 |
| Total number of active participants reported on line 7a of the Form 5500 | 2022-03-01 | 1,629 |
| Number of retired or separated participants receiving benefits | 2022-03-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2022-03-01 | 0 |
| Total of all active and inactive participants | 2022-03-01 | 1,629 |
| Number of employers contributing to the scheme | 2022-03-01 | 0 |
| 2021: GRAND LAKE MENTAL HEALTH CENTER, INC. WELFARE BENEFIT PLAN 2021 401k membership |
|---|
| Total participants, beginning-of-year | 2021-03-01 | 937 |
| Total number of active participants reported on line 7a of the Form 5500 | 2021-03-01 | 1,165 |
| Number of retired or separated participants receiving benefits | 2021-03-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2021-03-01 | 0 |
| Total of all active and inactive participants | 2021-03-01 | 1,165 |
| Number of employers contributing to the scheme | 2021-03-01 | 0 |
| 2020: GRAND LAKE MENTAL HEALTH CENTER, INC. WELFARE BENEFIT PLAN 2020 401k membership |
|---|
| Total participants, beginning-of-year | 2020-03-01 | 850 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-03-01 | 937 |
| Number of retired or separated participants receiving benefits | 2020-03-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2020-03-01 | 0 |
| Total of all active and inactive participants | 2020-03-01 | 937 |
| Number of employers contributing to the scheme | 2020-03-01 | 0 |
| 2019: GRAND LAKE MENTAL HEALTH CENTER, INC. WELFARE BENEFIT PLAN 2019 401k membership |
|---|
| Total participants, beginning-of-year | 2019-03-01 | 621 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-03-01 | 824 |
| Number of retired or separated participants receiving benefits | 2019-03-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2019-03-01 | 0 |
| Total of all active and inactive participants | 2019-03-01 | 824 |
| Number of employers contributing to the scheme | 2019-03-01 | 0 |
| 2018: GRAND LAKE MENTAL HEALTH CENTER, INC. WELFARE BENEFIT PLAN 2018 401k membership |
|---|
| Total participants, beginning-of-year | 2018-03-01 | 179 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-03-01 | 621 |
| Number of retired or separated participants receiving benefits | 2018-03-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2018-03-01 | 0 |
| Total of all active and inactive participants | 2018-03-01 | 621 |
| Number of employers contributing to the scheme | 2018-03-01 | 0 |
| 2017: GRAND LAKE MENTAL HEALTH CENTER, INC. WELFARE BENEFIT PLAN 2017 401k membership |
|---|
| Total participants, beginning-of-year | 2017-03-01 | 348 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-03-01 | 479 |
| Number of retired or separated participants receiving benefits | 2017-03-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2017-03-01 | 0 |
| Total of all active and inactive participants | 2017-03-01 | 479 |
| Number of employers contributing to the scheme | 2017-03-01 | 0 |
| 2016: GRAND LAKE MENTAL HEALTH CENTER, INC. WELFARE BENEFIT PLAN 2016 401k membership |
|---|
| Total participants, beginning-of-year | 2016-03-01 | 295 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-03-01 | 348 |
| Number of retired or separated participants receiving benefits | 2016-03-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2016-03-01 | 0 |
| Total of all active and inactive participants | 2016-03-01 | 348 |
| Number of employers contributing to the scheme | 2016-03-01 | 0 |
| 2015: GRAND LAKE MENTAL HEALTH CENTER, INC. WELFARE BENEFIT PLAN 2015 401k membership |
|---|
| Total participants, beginning-of-year | 2015-03-01 | 100 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-03-01 | 295 |
| Number of retired or separated participants receiving benefits | 2015-03-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2015-03-01 | 0 |
| Total of all active and inactive participants | 2015-03-01 | 295 |
| Number of employers contributing to the scheme | 2015-03-01 | 0 |
| STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 ) |
| Policy contract number | 167298 |
| Policy instance | 5 |
| Insurance contract or identification number | 167298 | | Number of Individuals Covered | 1629 | | Insurance policy start date | 2022-03-01 | | Insurance policy end date | 2023-02-28 | | Total amount of commissions paid to insurance broker | USD $164,634 | | Total amount of fees paid to insurance company | USD $83,736 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENT, CRITICAL ILLNESS | | Welfare Benefit Premiums Paid to Carrier | USD $271,370 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $125,407 | | Amount paid for insurance broker fees | 5841 | | Additional information about fees paid to insurance broker | CONTINGENT COMPENSATION | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL (National Association of Insurance Commissioners NAIC id number: 53937 ) |
| Policy contract number | 4139 |
| Policy instance | 1 |
| Insurance contract or identification number | 4139 | | Number of Individuals Covered | 1202 | | Insurance policy start date | 2022-03-01 | | Insurance policy end date | 2023-02-28 | | Total amount of commissions paid to insurance broker | USD $54,319 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $54,319 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUC0BBNV |
| Policy instance | 2 |
| Insurance contract or identification number | GUC0BBNV | | Number of Individuals Covered | 499 | | Insurance policy start date | 2022-03-01 | | Insurance policy end date | 2023-02-28 | | Total amount of commissions paid to insurance broker | USD $38,747 | | Total amount of fees paid to insurance company | USD $9,245 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $258,315 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $38,747 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION |
|
| LEADERS LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 74799 ) |
| Policy contract number | 406 |
| Policy instance | 3 |
| Insurance contract or identification number | 406 | | Number of Individuals Covered | 45 | | Insurance policy start date | 2022-03-01 | | Insurance policy end date | 2023-02-28 | | Total amount of commissions paid to insurance broker | USD $4,568 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $14,261 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,690 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| NEW BENEFITS LTD TELADOC HEALTH ADVOCATE AND UNITED HEALTHCARE GLO (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | HUB1008W |
| Policy instance | 4 |
| Insurance contract or identification number | HUB1008W | | Number of Individuals Covered | 1695 | | Insurance policy start date | 2022-03-01 | | Insurance policy end date | 2023-02-28 | | Total amount of commissions paid to insurance broker | USD $34,223 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $133,380 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $34,223 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 ) |
| Policy contract number | 167298 |
| Policy instance | 6 |
| Insurance contract or identification number | 167298 | | Number of Individuals Covered | 1165 | | Insurance policy start date | 2021-03-01 | | Insurance policy end date | 2022-02-28 | | Total amount of commissions paid to insurance broker | USD $87,765 | | Total amount of fees paid to insurance company | USD $47,357 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENT, CRITICAL ILLNESS | | Welfare Benefit Premiums Paid to Carrier | USD $98,679 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $87,765 | | Amount paid for insurance broker fees | 20666 | | Additional information about fees paid to insurance broker | ADMINISTRATION | | Insurance broker organization code? | 3 |
|
| LEADERS LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 74799 ) |
| Policy contract number | 406 |
| Policy instance | 4 |
| Insurance contract or identification number | 406 | | Number of Individuals Covered | 37 | | Insurance policy start date | 2021-03-01 | | Insurance policy end date | 2022-02-28 | | Total amount of commissions paid to insurance broker | USD $1,496 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $9,853 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,408 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUC0BBNV |
| Policy instance | 3 |
| Insurance contract or identification number | GUC0BBNV | | Number of Individuals Covered | 249 | | Insurance policy start date | 2021-03-01 | | Insurance policy end date | 2022-02-28 | | Total amount of commissions paid to insurance broker | USD $16,211 | | Total amount of fees paid to insurance company | USD $4,013 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $108,071 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $14,600 | | Amount paid for insurance broker fees | 4013 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| PRIMARY CARE VISION SERVICES (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 1 |
| Policy instance | 2 |
| Insurance contract or identification number | 1 | | Number of Individuals Covered | 1242 | | Insurance policy start date | 2021-03-01 | | Insurance policy end date | 2022-02-28 | | Total amount of commissions paid to insurance broker | USD $14,464 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $123,530 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $12,223 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL (National Association of Insurance Commissioners NAIC id number: 53937 ) |
| Policy contract number | 4139 |
| Policy instance | 1 |
| Insurance contract or identification number | 4139 | | Number of Individuals Covered | 814 | | Insurance policy start date | 2021-03-01 | | Insurance policy end date | 2022-02-28 | | Total amount of commissions paid to insurance broker | USD $38,070 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $31,116 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| NEW BENEFITS LTD TELADOC HEALTH ADVOCATE AND UNITED HEALTHCARE GLO (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | HUB1008W |
| Policy instance | 5 |
| Insurance contract or identification number | HUB1008W | | Number of Individuals Covered | 1228 | | Insurance policy start date | 2021-03-01 | | Insurance policy end date | 2022-02-28 | | Total amount of commissions paid to insurance broker | USD $4,801 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $95,053 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,801 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL (National Association of Insurance Commissioners NAIC id number: 53937 ) |
| Policy contract number | 4139 |
| Policy instance | 1 |
| Insurance contract or identification number | 4139 | | Number of Individuals Covered | 645 | | Insurance policy start date | 2020-03-01 | | Insurance policy end date | 2021-02-28 | | Total amount of commissions paid to insurance broker | USD $32,749 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $32,749 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 ) |
| Policy contract number | 167298 |
| Policy instance | 7 |
| Insurance contract or identification number | 167298 | | Number of Individuals Covered | 937 | | Insurance policy start date | 2020-03-01 | | Insurance policy end date | 2021-02-28 | | Total amount of commissions paid to insurance broker | USD $19,702 | | Total amount of fees paid to insurance company | USD $9,065 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $19,702 | | Amount paid for insurance broker fees | 9065 | | Additional information about fees paid to insurance broker | ADMINISTRATION | | Insurance broker organization code? | 3 |
|
| STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 ) |
| Policy contract number | 167298 |
| Policy instance | 6 |
| Insurance contract or identification number | 167298 | | Number of Individuals Covered | 324 | | Insurance policy start date | 2020-03-01 | | Insurance policy end date | 2021-02-28 | | Total amount of commissions paid to insurance broker | USD $58,621 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | ACCIDENT, CRITICAL ILLNESS | | Welfare Benefit Premiums Paid to Carrier | USD $105,018 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $58,621 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| NEW BENEFITS LTD TELADOC HEALTH ADVOCATE AND UNITED HEALTHCARE GLO (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | HUB1008W |
| Policy instance | 5 |
| Insurance contract or identification number | HUB1008W | | Number of Individuals Covered | 934 | | Insurance policy start date | 2020-03-01 | | Insurance policy end date | 2021-02-28 | | Total amount of commissions paid to insurance broker | USD $4,207 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $81,989 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $4,207 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| LEADERS LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 74799 ) |
| Policy contract number | 406 |
| Policy instance | 4 |
| Insurance contract or identification number | 406 | | Number of Individuals Covered | 38 | | Insurance policy start date | 2020-03-01 | | Insurance policy end date | 2021-02-28 | | Total amount of commissions paid to insurance broker | USD $2,808 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $10,545 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,686 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUC0BBNV |
| Policy instance | 3 |
| Insurance contract or identification number | GUC0BBNV | | Number of Individuals Covered | 161 | | Insurance policy start date | 2020-03-01 | | Insurance policy end date | 2021-02-28 | | Total amount of commissions paid to insurance broker | USD $11,137 | | Total amount of fees paid to insurance company | USD $3,046 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $74,249 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $11,137 | | Amount paid for insurance broker fees | 3046 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| PRIMARY CARE VISION SERVICES (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 1 |
| Policy instance | 2 |
| Insurance contract or identification number | 1 | | Number of Individuals Covered | 1007 | | Insurance policy start date | 2020-03-01 | | Insurance policy end date | 2021-02-28 | | Total amount of commissions paid to insurance broker | USD $10,557 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $105,566 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $10,557 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL (National Association of Insurance Commissioners NAIC id number: 53937 ) |
| Policy contract number | 4139 |
| Policy instance | 1 |
| Insurance contract or identification number | 4139 | | Number of Individuals Covered | 577 | | Insurance policy start date | 2019-03-01 | | Insurance policy end date | 2020-02-29 | | Total amount of commissions paid to insurance broker | USD $24,072 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $24,072 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| THE MANHATTAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 9999 ) |
| Policy contract number | 00 |
| Policy instance | 3 |
| Insurance contract or identification number | 00 | | Number of Individuals Covered | 271 | | Insurance policy start date | 2019-03-01 | | Insurance policy end date | 2020-02-29 | | Total amount of commissions paid to insurance broker | USD $7,824 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | ACCIDENT, CRITICAL ILLNESS, CANCER | | Welfare Benefit Premiums Paid to Carrier | USD $20,170 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,137 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 540358 |
| Policy instance | 4 |
| Insurance contract or identification number | 540358 | | Number of Individuals Covered | 824 | | Insurance policy start date | 2019-03-01 | | Insurance policy end date | 2020-02-29 | | Total amount of commissions paid to insurance broker | USD $9,398 | | Total amount of fees paid to insurance company | USD $10,871 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $312,587 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $9,398 | | Amount paid for insurance broker fees | 10871 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUC0BBNV |
| Policy instance | 5 |
| Insurance contract or identification number | GUC0BBNV | | Number of Individuals Covered | 118 | | Insurance policy start date | 2019-03-01 | | Insurance policy end date | 2020-02-29 | | Total amount of commissions paid to insurance broker | USD $7,349 | | Total amount of fees paid to insurance company | USD $1,140 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $48,991 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,349 | | Amount paid for insurance broker fees | 1140 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| LEADERS LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 74799 ) |
| Policy contract number | 406 |
| Policy instance | 6 |
| Insurance contract or identification number | 406 | | Number of Individuals Covered | 824 | | Insurance policy start date | 2019-03-01 | | Insurance policy end date | 2020-02-29 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| PRIMARY CARE VISION SERVICES (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 1 |
| Policy instance | 2 |
| Insurance contract or identification number | 1 | | Number of Individuals Covered | 490 | | Insurance policy start date | 2019-03-01 | | Insurance policy end date | 2020-02-29 | | Total amount of commissions paid to insurance broker | USD $7,447 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $74,467 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,447 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| HUMANA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 73288 ) |
| Policy contract number | 00 |
| Policy instance | 3 |
| Insurance contract or identification number | 00 | | Number of Individuals Covered | 621 | | Insurance policy start date | 2018-03-01 | | Insurance policy end date | 2019-02-28 | | Total amount of commissions paid to insurance broker | USD $2,935 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | ACCIDENT, CRITICAL ILLNESS, CANCER | | Welfare Benefit Premiums Paid to Carrier | USD $5,961 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $2,433 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| LEADERS LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 74799 ) |
| Policy contract number | 406 |
| Policy instance | 7 |
| Insurance contract or identification number | 406 | | Number of Individuals Covered | 621 | | Insurance policy start date | 2018-03-01 | | Insurance policy end date | 2019-02-28 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| THE MANHATTAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 9999 ) |
| Policy contract number | 00 |
| Policy instance | 6 |
| Insurance contract or identification number | 00 | | Number of Individuals Covered | 189 | | Insurance policy start date | 2018-03-01 | | Insurance policy end date | 2019-02-28 | | Total amount of commissions paid to insurance broker | USD $6,605 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | ACCIDENT, CRITICAL ILLNESS, CANCER | | Welfare Benefit Premiums Paid to Carrier | USD $13,252 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,486 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUC0BBNV |
| Policy instance | 5 |
| Insurance contract or identification number | GUC0BBNV | | Number of Individuals Covered | 58 | | Insurance policy start date | 2018-03-01 | | Insurance policy end date | 2019-02-28 | | Total amount of commissions paid to insurance broker | USD $4,517 | | Total amount of fees paid to insurance company | USD $0 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $30,116 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,517 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 540358 |
| Policy instance | 4 |
| Insurance contract or identification number | 540358 | | Number of Individuals Covered | 621 | | Insurance policy start date | 2018-03-01 | | Insurance policy end date | 2019-02-28 | | Total amount of commissions paid to insurance broker | USD $9,457 | | Total amount of fees paid to insurance company | USD $2,875 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $284,463 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $9,457 | | Amount paid for insurance broker fees | 2875 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker organization code? | 3 |
|
| PRIMARY CARE VISION SERVICES (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 1 |
| Policy instance | 2 |
| Insurance contract or identification number | 1 | | Number of Individuals Covered | 549 | | Insurance policy start date | 2018-03-01 | | Insurance policy end date | 2019-02-28 | | Total amount of commissions paid to insurance broker | USD $8,237 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $82,374 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,237 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL (National Association of Insurance Commissioners NAIC id number: 53937 ) |
| Policy contract number | 4139 |
| Policy instance | 1 |
| Insurance contract or identification number | 4139 | | Number of Individuals Covered | 532 | | Insurance policy start date | 2018-03-01 | | Insurance policy end date | 2019-02-28 | | Total amount of commissions paid to insurance broker | USD $23,672 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $23,672 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 140376 |
| Policy instance | 4 |
| Insurance contract or identification number | 140376 | | Number of Individuals Covered | 348 | | Insurance policy start date | 2016-07-01 | | Insurance policy end date | 2017-06-30 | | Total amount of commissions paid to insurance broker | USD $9,426 | | Total amount of fees paid to insurance company | USD $420 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $170,340 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,053 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION |
|
| LEADERS LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 74799 ) |
| Policy contract number | 406 |
| Policy instance | 7 |
| Insurance contract or identification number | 406 | | Number of Individuals Covered | 1 | | Insurance policy start date | 2017-03-01 | | Insurance policy end date | 2018-02-28 | | Total amount of commissions paid to insurance broker | USD $3,571 | | Total amount of fees paid to insurance company | USD $0 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $8,006 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,594 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| LEADERS LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 74799 ) |
| Policy contract number | 406 |
| Policy instance | 6 |
| Insurance contract or identification number | 406 | | Number of Individuals Covered | 31 | | Insurance policy start date | 2017-03-01 | | Insurance policy end date | 2018-02-28 | | Total amount of commissions paid to insurance broker | USD $4,702 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $16,814 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,635 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 540358 |
| Policy instance | 5 |
| Insurance contract or identification number | 540358 | | Number of Individuals Covered | 479 | | Insurance policy start date | 2017-07-01 | | Insurance policy end date | 2018-02-28 | | Total amount of commissions paid to insurance broker | USD $7,970 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $114,057 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,970 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL (National Association of Insurance Commissioners NAIC id number: 53937 ) |
| Policy contract number | 4139 |
| Policy instance | 1 |
| Insurance contract or identification number | 4139 | | Number of Individuals Covered | 273 | | Insurance policy start date | 2017-03-01 | | Insurance policy end date | 2018-02-28 | | Total amount of commissions paid to insurance broker | USD $10,390 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $10,390 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| PRIMARY CARE VISION SERVICES (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 1 |
| Policy instance | 2 |
| Insurance contract or identification number | 1 | | Number of Individuals Covered | 302 | | Insurance policy start date | 2017-03-01 | | Insurance policy end date | 2018-02-28 | | Total amount of commissions paid to insurance broker | USD $3,480 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $34,797 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,480 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| HUMANA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 73288 ) |
| Policy contract number | 00 |
| Policy instance | 3 |
| Insurance contract or identification number | 00 | | Number of Individuals Covered | 133 | | Insurance policy start date | 2017-03-01 | | Insurance policy end date | 2018-02-28 | | Total amount of commissions paid to insurance broker | USD $5,207 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | ACCIDENT, CRITICAL ILLNESS, CANCER | | Welfare Benefit Premiums Paid to Carrier | USD $10,860 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,961 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| PRIMARY CARE VISION SERVICES (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 1 |
| Policy instance | 2 |
| Insurance contract or identification number | 1 | | Number of Individuals Covered | 179 | | Insurance policy start date | 2016-03-01 | | Insurance policy end date | 2017-02-28 | | Total amount of commissions paid to insurance broker | USD $2,352 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $23,518 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,352 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| HUMANA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 73288 ) |
| Policy contract number | 00 |
| Policy instance | 3 |
| Insurance contract or identification number | 00 | | Number of Individuals Covered | 47 | | Insurance policy start date | 2016-03-01 | | Insurance policy end date | 2017-02-28 | | Total amount of commissions paid to insurance broker | USD $2,893 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | ACCIDENT, CRITICAL ILLNESS, CANCER | | Welfare Benefit Premiums Paid to Carrier | USD $6,300 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,368 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| LEADERS LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 74799 ) |
| Policy contract number | 406 |
| Policy instance | 6 |
| Insurance contract or identification number | 406 | | Number of Individuals Covered | 9 | | Insurance policy start date | 2016-03-01 | | Insurance policy end date | 2017-02-28 | | Total amount of commissions paid to insurance broker | USD $1,583 | | Total amount of fees paid to insurance company | USD $0 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $4,709 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,251 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL (National Association of Insurance Commissioners NAIC id number: 53937 ) |
| Policy contract number | 4139 |
| Policy instance | 1 |
| Insurance contract or identification number | 4139 | | Number of Individuals Covered | 177 | | Insurance policy start date | 2016-03-01 | | Insurance policy end date | 2017-02-28 | | Total amount of commissions paid to insurance broker | USD $7,687 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,687 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| LEADERS LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 74799 ) |
| Policy contract number | 406 |
| Policy instance | 5 |
| Insurance contract or identification number | 406 | | Number of Individuals Covered | 30 | | Insurance policy start date | 2016-03-01 | | Insurance policy end date | 2017-02-28 | | Total amount of commissions paid to insurance broker | USD $3,129 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $15,835 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,351 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 140376 |
| Policy instance | 4 |
| Insurance contract or identification number | 140376 | | Number of Individuals Covered | 295 | | Insurance policy start date | 2015-07-01 | | Insurance policy end date | 2016-06-30 | | Total amount of commissions paid to insurance broker | USD $7,838 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $119,244 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,838 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| LEADERS LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 74799 ) |
| Policy contract number | 406 |
| Policy instance | 5 |
| Insurance contract or identification number | 406 | | Number of Individuals Covered | 26 | | Insurance policy start date | 2015-03-01 | | Insurance policy end date | 2016-02-29 | | Total amount of commissions paid to insurance broker | USD $2,881 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $12,905 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,150 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| HUMANA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 73288 ) |
| Policy contract number | 00 |
| Policy instance | 3 |
| Insurance contract or identification number | 00 | | Number of Individuals Covered | 48 | | Insurance policy start date | 2015-03-01 | | Insurance policy end date | 2016-02-29 | | Total amount of commissions paid to insurance broker | USD $1,037 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | ACCIDENT, CRITICAL ILLNESS, CANCER | | Welfare Benefit Premiums Paid to Carrier | USD $4,448 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,037 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| PRIMARY CARE VISION SERVICES (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 1 |
| Policy instance | 2 |
| Insurance contract or identification number | 1 | | Number of Individuals Covered | 126 | | Insurance policy start date | 2015-03-01 | | Insurance policy end date | 2016-02-29 | | Total amount of commissions paid to insurance broker | USD $1,462 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $14,621 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,462 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL (National Association of Insurance Commissioners NAIC id number: 53937 ) |
| Policy contract number | 4139 |
| Policy instance | 1 |
| Insurance contract or identification number | 4139 | | Number of Individuals Covered | 130 | | Insurance policy start date | 2015-03-01 | | Insurance policy end date | 2016-02-29 | | Total amount of commissions paid to insurance broker | USD $5,060 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,060 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 140376 |
| Policy instance | 4 |
| Insurance contract or identification number | 140376 | | Number of Individuals Covered | 247 | | Insurance policy start date | 2014-07-01 | | Insurance policy end date | 2015-06-30 | | Total amount of commissions paid to insurance broker | USD $7,993 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $123,273 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,993 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
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