MACK ENERGY CO. has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan MACK ENERGY INSURED WELFARE PLAN
| Measure | Date | Value |
|---|
| 2022: MACK ENERGY INSURED WELFARE PLAN 2022 401k membership |
|---|
| Total participants, beginning-of-year | 2022-03-01 | 148 |
| Total number of active participants reported on line 7a of the Form 5500 | 2022-03-01 | 124 |
| Number of retired or separated participants receiving benefits | 2022-03-01 | 7 |
| Number of other retired or separated participants entitled to future benefits | 2022-03-01 | 14 |
| Total of all active and inactive participants | 2022-03-01 | 145 |
| 2021: MACK ENERGY INSURED WELFARE PLAN 2021 401k membership |
|---|
| Total participants, beginning-of-year | 2021-03-01 | 149 |
| Total number of active participants reported on line 7a of the Form 5500 | 2021-03-01 | 129 |
| Number of retired or separated participants receiving benefits | 2021-03-01 | 4 |
| Number of other retired or separated participants entitled to future benefits | 2021-03-01 | 15 |
| Total of all active and inactive participants | 2021-03-01 | 148 |
| 2020: MACK ENERGY INSURED WELFARE PLAN 2020 401k membership |
|---|
| Total participants, beginning-of-year | 2020-12-01 | 292 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-12-01 | 129 |
| Number of retired or separated participants receiving benefits | 2020-12-01 | 4 |
| Number of other retired or separated participants entitled to future benefits | 2020-12-01 | 16 |
| Total of all active and inactive participants | 2020-12-01 | 149 |
| 2019: MACK ENERGY INSURED WELFARE PLAN 2019 401k membership |
|---|
| Total participants, beginning-of-year | 2019-12-01 | 292 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-12-01 | 292 |
| Total of all active and inactive participants | 2019-12-01 | 292 |
| Total participants | 2019-12-01 | 292 |
| 2018: MACK ENERGY INSURED WELFARE PLAN 2018 401k membership |
|---|
| Total participants, beginning-of-year | 2018-12-01 | 583 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-12-01 | 583 |
| Total of all active and inactive participants | 2018-12-01 | 583 |
| Total participants | 2018-12-01 | 583 |
| 2017: MACK ENERGY INSURED WELFARE PLAN 2017 401k membership |
|---|
| Total participants, beginning-of-year | 2017-12-01 | 121 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-12-01 | 121 |
| Total of all active and inactive participants | 2017-12-01 | 121 |
| Total participants | 2017-12-01 | 121 |
| 2016: MACK ENERGY INSURED WELFARE PLAN 2016 401k membership |
|---|
| Total participants, beginning-of-year | 2016-12-01 | 119 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-12-01 | 119 |
| Total of all active and inactive participants | 2016-12-01 | 119 |
| Total participants | 2016-12-01 | 119 |
| 2015: MACK ENERGY INSURED WELFARE PLAN 2015 401k membership |
|---|
| Total participants, beginning-of-year | 2015-12-01 | 204 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-12-01 | 119 |
| Total of all active and inactive participants | 2015-12-01 | 119 |
| Total participants | 2015-12-01 | 0 |
| 2014: MACK ENERGY INSURED WELFARE PLAN 2014 401k membership |
|---|
| Total participants, beginning-of-year | 2014-12-01 | 210 |
| Total number of active participants reported on line 7a of the Form 5500 | 2014-12-01 | 204 |
| Total of all active and inactive participants | 2014-12-01 | 204 |
| Total participants | 2014-12-01 | 0 |
| 2013: MACK ENERGY INSURED WELFARE PLAN 2013 401k membership |
|---|
| Total participants, beginning-of-year | 2013-12-01 | 206 |
| Total number of active participants reported on line 7a of the Form 5500 | 2013-12-01 | 210 |
| Total of all active and inactive participants | 2013-12-01 | 210 |
| Total participants | 2013-12-01 | 0 |
| 2012: MACK ENERGY INSURED WELFARE PLAN 2012 401k membership |
|---|
| Total participants, beginning-of-year | 2012-12-01 | 188 |
| Total number of active participants reported on line 7a of the Form 5500 | 2012-12-01 | 206 |
| Total of all active and inactive participants | 2012-12-01 | 206 |
| Total participants | 2012-12-01 | 0 |
| 2011: MACK ENERGY INSURED WELFARE PLAN 2011 401k membership |
|---|
| Total participants, beginning-of-year | 2011-12-01 | 179 |
| Total number of active participants reported on line 7a of the Form 5500 | 2011-12-01 | 188 |
| Total of all active and inactive participants | 2011-12-01 | 188 |
| Total participants | 2011-12-01 | 188 |
| 2010: MACK ENERGY INSURED WELFARE PLAN 2010 401k membership |
|---|
| Total participants, beginning-of-year | 2010-12-01 | 173 |
| Total number of active participants reported on line 7a of the Form 5500 | 2010-12-01 | 179 |
| Total of all active and inactive participants | 2010-12-01 | 179 |
| Total participants | 2010-12-01 | 179 |
| 2009: MACK ENERGY INSURED WELFARE PLAN 2009 401k membership |
|---|
| Total participants, beginning-of-year | 2009-12-01 | 115 |
| Total number of active participants reported on line 7a of the Form 5500 | 2009-12-01 | 173 |
| Total of all active and inactive participants | 2009-12-01 | 173 |
| Total participants | 2009-12-01 | 173 |
| Measure | Date | Value |
|---|
| 2014 : MACK ENERGY INSURED WELFARE PLAN 2014 401k financial data |
|---|
| Value of total assets at end of year | 2014-11-30 | $0 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2014-11-30 | No |
| Was this plan covered by a fidelity bond | 2014-11-30 | No |
| If this is an individual account plan, was there a blackout period | 2014-11-30 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2014-11-30 | No |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2014-11-30 | No |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2014-11-30 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2014-11-30 | No |
| Were any leases to which the plan was party in default or uncollectible | 2014-11-30 | No |
| Value of interest in common/collective trusts at end of year | 2014-11-30 | $0 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2014-11-30 | No |
| Was there a failure to transmit to the plan any participant contributions | 2014-11-30 | No |
| Has the plan failed to provide any benefit when due under the plan | 2014-11-30 | No |
| Did the plan have assets held for investment | 2014-11-30 | No |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2014-11-30 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2014-11-30 | No |
| 2011 : MACK ENERGY INSURED WELFARE PLAN 2011 401k financial data |
|---|
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2011-11-30 | No |
| Was this plan covered by a fidelity bond | 2011-11-30 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2011-11-30 | No |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2011-11-30 | No |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2011-11-30 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2011-11-30 | No |
| Were any leases to which the plan was party in default or uncollectible | 2011-11-30 | No |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2011-11-30 | No |
| Was there a failure to transmit to the plan any participant contributions | 2011-11-30 | No |
| Has the plan failed to provide any benefit when due under the plan | 2011-11-30 | No |
| Did the plan have assets held for investment | 2011-11-30 | No |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2011-11-30 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2011-11-30 | No |
| 2022: MACK ENERGY INSURED WELFARE PLAN 2022 form 5500 responses |
|---|
| 2022-03-01 | Type of plan entity | Single employer plan |
| 2022-03-01 | Submission has been amended | No |
| 2022-03-01 | This submission is the final filing | No |
| 2022-03-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2022-03-01 | Plan is a collectively bargained plan | No |
| 2022-03-01 | Plan funding arrangement – Insurance | Yes |
| 2022-03-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2022-03-01 | Plan benefit arrangement – Insurance | Yes |
| 2022-03-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2021: MACK ENERGY INSURED WELFARE PLAN 2021 form 5500 responses |
|---|
| 2021-03-01 | Type of plan entity | Single employer plan |
| 2021-03-01 | Submission has been amended | No |
| 2021-03-01 | This submission is the final filing | No |
| 2021-03-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2021-03-01 | Plan is a collectively bargained plan | No |
| 2021-03-01 | Plan funding arrangement – Insurance | Yes |
| 2021-03-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2021-03-01 | Plan benefit arrangement – Insurance | Yes |
| 2021-03-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2020: MACK ENERGY INSURED WELFARE PLAN 2020 form 5500 responses |
|---|
| 2020-12-01 | Type of plan entity | Single employer plan |
| 2020-12-01 | Submission has been amended | No |
| 2020-12-01 | This submission is the final filing | No |
| 2020-12-01 | This return/report is a short plan year return/report (less than 12 months) | Yes |
| 2020-12-01 | Plan is a collectively bargained plan | No |
| 2020-12-01 | Plan funding arrangement – Insurance | Yes |
| 2020-12-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2020-12-01 | Plan benefit arrangement – Insurance | Yes |
| 2020-12-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2019: MACK ENERGY INSURED WELFARE PLAN 2019 form 5500 responses |
|---|
| 2019-12-01 | Type of plan entity | Single employer plan |
| 2019-12-01 | Plan funding arrangement – Insurance | Yes |
| 2019-12-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2019-12-01 | Plan benefit arrangement – Insurance | Yes |
| 2019-12-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2018: MACK ENERGY INSURED WELFARE PLAN 2018 form 5500 responses |
|---|
| 2018-12-01 | Type of plan entity | Single employer plan |
| 2018-12-01 | Plan funding arrangement – Insurance | Yes |
| 2018-12-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2018-12-01 | Plan benefit arrangement – Insurance | Yes |
| 2018-12-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2017: MACK ENERGY INSURED WELFARE PLAN 2017 form 5500 responses |
|---|
| 2017-12-01 | Type of plan entity | Single employer plan |
| 2017-12-01 | Plan funding arrangement – Insurance | Yes |
| 2017-12-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2017-12-01 | Plan benefit arrangement – Insurance | Yes |
| 2017-12-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2016: MACK ENERGY INSURED WELFARE PLAN 2016 form 5500 responses |
|---|
| 2016-12-01 | Type of plan entity | Single employer plan |
| 2016-12-01 | Plan funding arrangement – Insurance | Yes |
| 2016-12-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2016-12-01 | Plan benefit arrangement – Insurance | Yes |
| 2016-12-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2015: MACK ENERGY INSURED WELFARE PLAN 2015 form 5500 responses |
|---|
| 2015-12-01 | Type of plan entity | Single employer plan |
| 2015-12-01 | Plan funding arrangement – Insurance | Yes |
| 2015-12-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2015-12-01 | Plan benefit arrangement – Insurance | Yes |
| 2015-12-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2014: MACK ENERGY INSURED WELFARE PLAN 2014 form 5500 responses |
|---|
| 2014-12-01 | Type of plan entity | Single employer plan |
| 2014-12-01 | Plan funding arrangement – Insurance | Yes |
| 2014-12-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2014-12-01 | Plan benefit arrangement – Insurance | Yes |
| 2014-12-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2013: MACK ENERGY INSURED WELFARE PLAN 2013 form 5500 responses |
|---|
| 2013-12-01 | Type of plan entity | Single employer plan |
| 2013-12-01 | Plan funding arrangement – Insurance | Yes |
| 2013-12-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2013-12-01 | Plan benefit arrangement – Insurance | Yes |
| 2013-12-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2012: MACK ENERGY INSURED WELFARE PLAN 2012 form 5500 responses |
|---|
| 2012-12-01 | Type of plan entity | Single employer plan |
| 2012-12-01 | Plan funding arrangement – Insurance | Yes |
| 2012-12-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2012-12-01 | Plan benefit arrangement – Insurance | Yes |
| 2012-12-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2011: MACK ENERGY INSURED WELFARE PLAN 2011 form 5500 responses |
|---|
| 2011-12-01 | Type of plan entity | Single employer plan |
| 2011-12-01 | Plan funding arrangement – Insurance | Yes |
| 2011-12-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2011-12-01 | Plan benefit arrangement – Insurance | Yes |
| 2011-12-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2010: MACK ENERGY INSURED WELFARE PLAN 2010 form 5500 responses |
|---|
| 2010-12-01 | Type of plan entity | Single employer plan |
| 2010-12-01 | Plan funding arrangement – Insurance | Yes |
| 2010-12-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2010-12-01 | Plan benefit arrangement – Insurance | Yes |
| 2010-12-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2009: MACK ENERGY INSURED WELFARE PLAN 2009 form 5500 responses |
|---|
| 2009-12-01 | Type of plan entity | Single employer plan |
| 2009-12-01 | Submission has been amended | Yes |
| 2009-12-01 | Plan funding arrangement – Insurance | Yes |
| 2009-12-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2009-12-01 | Plan benefit arrangement – Insurance | Yes |
| 2009-12-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 ) |
| Policy contract number | 80308 |
| Policy instance | 5 |
| Insurance contract or identification number | 80308 | | Number of Individuals Covered | 46 | | Insurance policy start date | 2022-03-01 | | Insurance policy end date | 2023-02-28 | | Total amount of commissions paid to insurance broker | USD $3,870 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | CANCER, ACCIDENT | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $23,246 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,870 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | COMMISSIONS | | Insurance broker organization code? | 3 |
|
| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
| Policy contract number | 803443G |
| Policy instance | 4 |
| Insurance contract or identification number | 803443G | | Number of Individuals Covered | 131 | | Insurance policy start date | 2022-03-01 | | Insurance policy end date | 2023-02-28 | | Total amount of commissions paid to insurance broker | USD $23,289 | | Total amount of fees paid to insurance company | USD $3,717 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT, EAP | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $168,509 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $23,289 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | COMMISSIONS | | Insurance broker organization code? | 3 |
|
| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
| Policy contract number | 5950959 |
| Policy instance | 3 |
| Insurance contract or identification number | 5950959 | | Number of Individuals Covered | 290 | | Insurance policy start date | 2022-03-01 | | Insurance policy end date | 2023-02-28 | | Total amount of commissions paid to insurance broker | USD $2,024 | | Total amount of fees paid to insurance company | USD $62 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $18,818 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,861 | | Amount paid for insurance broker fees | 62 | | Additional information about fees paid to insurance broker | COMMISSIONS AND FEES | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL (National Association of Insurance Commissioners NAIC id number: 53937 ) |
| Policy contract number | 3258 |
| Policy instance | 2 |
| Insurance contract or identification number | 3258 | | Number of Individuals Covered | 99 | | Insurance policy start date | 2022-03-01 | | Insurance policy end date | 2023-02-28 | | Total amount of commissions paid to insurance broker | USD $6,114 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $0 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,114 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | COMMISSIONS | | Insurance broker organization code? | 3 |
|
| BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 ) |
| Policy contract number | 411602 |
| Policy instance | 1 |
| Insurance contract or identification number | 411602 | | Number of Individuals Covered | 226 | | Insurance policy start date | 2022-03-01 | | Insurance policy end date | 2023-02-28 | | Total amount of commissions paid to insurance broker | USD $88,305 | | Total amount of fees paid to insurance company | USD $2,500 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $1,765,666 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $88,305 | | Amount paid for insurance broker fees | 2500 | | Additional information about fees paid to insurance broker | COMMISSIONS AND SPECIAL PROGRAMS | | Insurance broker organization code? | 3 |
|
| BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 ) |
| Policy contract number | 411602 |
| Policy instance | 1 |
| Insurance contract or identification number | 411602 | | Number of Individuals Covered | 223 | | Insurance policy start date | 2021-03-01 | | Insurance policy end date | 2022-02-28 | | Total amount of commissions paid to insurance broker | USD $84,948 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $1,699,410 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $84,948 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | COMMISSIONS | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL (National Association of Insurance Commissioners NAIC id number: 53937 ) |
| Policy contract number | 3258 |
| Policy instance | 2 |
| Insurance contract or identification number | 3258 | | Number of Individuals Covered | 100 | | Insurance policy start date | 2021-03-01 | | Insurance policy end date | 2022-02-28 | | Total amount of commissions paid to insurance broker | USD $5,887 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $0 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,887 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | COMMISSIONS | | Insurance broker organization code? | 3 |
|
| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
| Policy contract number | 5950959 |
| Policy instance | 3 |
| Insurance contract or identification number | 5950959 | | Number of Individuals Covered | 281 | | Insurance policy start date | 2021-03-01 | | Insurance policy end date | 2022-02-28 | | Total amount of commissions paid to insurance broker | USD $1,831 | | Total amount of fees paid to insurance company | USD $32 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $18,247 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,679 | | Amount paid for insurance broker fees | 32 | | Additional information about fees paid to insurance broker | COMMISSIONS AND FEES | | Insurance broker organization code? | 3 |
|
| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
| Policy contract number | 803443G |
| Policy instance | 4 |
| Insurance contract or identification number | 803443G | | Number of Individuals Covered | 129 | | Insurance policy start date | 2021-03-01 | | Insurance policy end date | 2022-02-28 | | Total amount of commissions paid to insurance broker | USD $16,964 | | Total amount of fees paid to insurance company | USD $1,864 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $113,093 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $16,964 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | COMMISSIONS | | Insurance broker organization code? | 3 |
|
| AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 ) |
| Policy contract number | 80308 |
| Policy instance | 5 |
| Insurance contract or identification number | 80308 | | Number of Individuals Covered | 41 | | Insurance policy start date | 2021-03-01 | | Insurance policy end date | 2022-02-28 | | Total amount of commissions paid to insurance broker | USD $2,874 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | CANCER, ACCIDENT | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $21,084 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,874 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | COMMISSIONS | | Insurance broker organization code? | 3 |
|
| AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 ) |
| Policy contract number | 80308 |
| Policy instance | 5 |
| Insurance contract or identification number | 80308 | | Number of Individuals Covered | 37 | | Insurance policy start date | 2020-12-01 | | Insurance policy end date | 2021-02-28 | | Total amount of commissions paid to insurance broker | USD $608 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | CANCER, ACCIDENT | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $7,095 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $608 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | COMMISSIONS | | Insurance broker organization code? | 3 |
|
| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
| Policy contract number | 803443G |
| Policy instance | 4 |
| Insurance contract or identification number | 803443G | | Number of Individuals Covered | 129 | | Insurance policy start date | 2020-12-01 | | Insurance policy end date | 2021-02-28 | | Total amount of commissions paid to insurance broker | USD $4,606 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $30,705 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,606 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | COMMISSIONS | | Insurance broker organization code? | 3 |
|
| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
| Policy contract number | 5950959 |
| Policy instance | 3 |
| Insurance contract or identification number | 5950959 | | Number of Individuals Covered | 292 | | Insurance policy start date | 2020-12-01 | | Insurance policy end date | 2021-02-28 | | Total amount of commissions paid to insurance broker | USD $575 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $2,823 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $422 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | COMMISSIONS | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL (National Association of Insurance Commissioners NAIC id number: 53937 ) |
| Policy contract number | 3258 |
| Policy instance | 2 |
| Insurance contract or identification number | 3258 | | Number of Individuals Covered | 95 | | Insurance policy start date | 2020-12-01 | | Insurance policy end date | 2021-02-28 | | Total amount of commissions paid to insurance broker | USD $1,146 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,146 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | COMMISSIONS | | Insurance broker organization code? | 3 |
|
| BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 ) |
| Policy contract number | 411602 |
| Policy instance | 1 |
| Insurance contract or identification number | 411602 | | Number of Individuals Covered | 99 | | Insurance policy start date | 2020-12-01 | | Insurance policy end date | 2021-02-28 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $418,631 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
| Policy contract number | 803443G |
| Policy instance | 4 |
| Insurance contract or identification number | 803443G | | Number of Individuals Covered | 129 | | Insurance policy start date | 2020-03-01 | | Insurance policy end date | 2021-02-28 | | Total amount of commissions paid to insurance broker | USD $18,570 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACC. DEATH & DISMEMBERMENT/ST DISAB | | Welfare Benefit Premiums Paid to Carrier | USD $123,796 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $18,570 | | Insurance broker organization code? | 3 |
|
| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
| Policy contract number | 5950959 |
| Policy instance | 3 |
| Insurance contract or identification number | 5950959 | | Number of Individuals Covered | 292 | | Insurance policy start date | 2020-03-01 | | Insurance policy end date | 2021-02-28 | | Total amount of commissions paid to insurance broker | USD $1,865 | | Total amount of fees paid to insurance company | USD $204 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $15,684 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,712 | | Amount paid for insurance broker fees | 204 | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL (National Association of Insurance Commissioners NAIC id number: 53937 ) |
| Policy contract number | 3258 |
| Policy instance | 2 |
| Insurance contract or identification number | 3258 | | Number of Individuals Covered | 95 | | Insurance policy start date | 2020-03-01 | | Insurance policy end date | 2021-02-28 | | Total amount of commissions paid to insurance broker | USD $5,671 | | Total amount of fees paid to insurance company | USD $6,895 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $90,450 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,671 | | Amount paid for insurance broker fees | 6895 | | Insurance broker organization code? | 3 |
|
| BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 ) |
| Policy contract number | 411602 |
| Policy instance | 1 |
| Insurance contract or identification number | 411602 | | Number of Individuals Covered | 220 | | Insurance policy start date | 2020-03-01 | | Insurance policy end date | 2021-02-28 | | Total amount of commissions paid to insurance broker | USD $82,542 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,684,439 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $82,542 | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL (National Association of Insurance Commissioners NAIC id number: 53937 ) |
| Policy contract number | 3258 |
| Policy instance | 2 |
| Insurance contract or identification number | 3258 | | Number of Individuals Covered | 94 | | Insurance policy start date | 2019-03-01 | | Insurance policy end date | 2020-02-29 | | Total amount of fees paid to insurance company | USD $5,494 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $91,568 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 5494 | | Insurance broker organization code? | 3 |
|
| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
| Policy contract number | 5950959 |
| Policy instance | 3 |
| Insurance contract or identification number | 5950959 | | Number of Individuals Covered | 308 | | Insurance policy start date | 2019-03-01 | | Insurance policy end date | 2020-02-29 | | Total amount of fees paid to insurance company | USD $1,772 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $16,405 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 1772 | | Insurance broker organization code? | 3 |
|
| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
| Policy contract number | 803443G |
| Policy instance | 4 |
| Insurance contract or identification number | 803443G | | Number of Individuals Covered | 250 | | Insurance policy start date | 2019-03-01 | | Insurance policy end date | 2020-02-29 | | Total amount of fees paid to insurance company | USD $18,108 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACC. DEATH & DISMEMBERMENT/ST DISAB | | Welfare Benefit Premiums Paid to Carrier | USD $120,717 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 18108 | | Insurance broker organization code? | 3 |
|
| BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 ) |
| Policy contract number | 411602 |
| Policy instance | 1 |
| Insurance contract or identification number | 411602 | | Number of Individuals Covered | 215 | | Insurance policy start date | 2019-03-01 | | Insurance policy end date | 2020-02-29 | | Total amount of commissions paid to insurance broker | USD $79,008 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,585,392 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $79,008 | | Insurance broker organization code? | 3 |
|
| BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 ) |
| Policy contract number | 411602 |
| Policy instance | 1 |
| Insurance contract or identification number | 411602 | | Number of Individuals Covered | 206 | | Insurance policy start date | 2018-03-01 | | Insurance policy end date | 2019-02-28 | | Total amount of commissions paid to insurance broker | USD $81,697 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,671,538 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 0869272 |
| Policy instance | 2 |
| Insurance contract or identification number | 0869272 | | Number of Individuals Covered | 121 | | Insurance policy start date | 2018-03-01 | | Insurance policy end date | 2019-02-28 | | Total amount of commissions paid to insurance broker | USD $16,781 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACC. DEATH & DISMEMBERMENT/ST DISAB | | Welfare Benefit Premiums Paid to Carrier | USD $115,077 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
| Policy contract number | 5950959 |
| Policy instance | 4 |
| Insurance contract or identification number | 5950959 | | Number of Individuals Covered | 298 | | Insurance policy start date | 2018-03-01 | | Insurance policy end date | 2019-02-28 | | Total amount of commissions paid to insurance broker | USD $1,660 | | Total amount of fees paid to insurance company | USD $619 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $16,860 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| DELTA DENTAL (National Association of Insurance Commissioners NAIC id number: 53937 ) |
| Policy contract number | 3258 |
| Policy instance | 3 |
| Insurance contract or identification number | 3258 | | Number of Individuals Covered | 87 | | Insurance policy start date | 2018-03-01 | | Insurance policy end date | 2019-02-28 | | Total amount of commissions paid to insurance broker | USD $5,274 | | Total amount of fees paid to insurance company | USD $6,987 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $87,900 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
