T AND W TIRE LLC has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan T AND W TIRE GROUP INSURANCE PLAN
| Measure | Date | Value |
|---|
| 2022: T AND W TIRE GROUP INSURANCE PLAN 2022 401k membership |
|---|
| Total participants, beginning-of-year | 2022-08-01 | 377 |
| Total number of active participants reported on line 7a of the Form 5500 | 2022-08-01 | 379 |
| Number of retired or separated participants receiving benefits | 2022-08-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2022-08-01 | 0 |
| Total of all active and inactive participants | 2022-08-01 | 379 |
| Number of employers contributing to the scheme | 2022-08-01 | 0 |
| 2021: T AND W TIRE GROUP INSURANCE PLAN 2021 401k membership |
|---|
| Total participants, beginning-of-year | 2021-08-01 | 352 |
| Total number of active participants reported on line 7a of the Form 5500 | 2021-08-01 | 368 |
| Number of retired or separated participants receiving benefits | 2021-08-01 | 1 |
| Number of other retired or separated participants entitled to future benefits | 2021-08-01 | 0 |
| Total of all active and inactive participants | 2021-08-01 | 369 |
| Number of employers contributing to the scheme | 2021-08-01 | 0 |
| 2020: T AND W TIRE GROUP INSURANCE PLAN 2020 401k membership |
|---|
| Total participants, beginning-of-year | 2020-08-01 | 357 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-08-01 | 361 |
| Number of retired or separated participants receiving benefits | 2020-08-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2020-08-01 | 0 |
| Total of all active and inactive participants | 2020-08-01 | 361 |
| Number of employers contributing to the scheme | 2020-08-01 | 0 |
| 2019: T AND W TIRE GROUP INSURANCE PLAN 2019 401k membership |
|---|
| Total participants, beginning-of-year | 2019-08-01 | 393 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-08-01 | 357 |
| Number of retired or separated participants receiving benefits | 2019-08-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2019-08-01 | 0 |
| Total of all active and inactive participants | 2019-08-01 | 357 |
| Number of employers contributing to the scheme | 2019-08-01 | 0 |
| 2018: T AND W TIRE GROUP INSURANCE PLAN 2018 401k membership |
|---|
| Total participants, beginning-of-year | 2018-08-01 | 429 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-08-01 | 393 |
| Number of retired or separated participants receiving benefits | 2018-08-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2018-08-01 | 0 |
| Total of all active and inactive participants | 2018-08-01 | 393 |
| Number of employers contributing to the scheme | 2018-08-01 | 0 |
| 2017: T AND W TIRE GROUP INSURANCE PLAN 2017 401k membership |
|---|
| Total participants, beginning-of-year | 2017-08-01 | 545 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-08-01 | 428 |
| Number of retired or separated participants receiving benefits | 2017-08-01 | 2 |
| Number of other retired or separated participants entitled to future benefits | 2017-08-01 | 0 |
| Total of all active and inactive participants | 2017-08-01 | 430 |
| Number of employers contributing to the scheme | 2017-08-01 | 0 |
| 2016: T AND W TIRE GROUP INSURANCE PLAN 2016 401k membership |
|---|
| Total participants, beginning-of-year | 2016-08-01 | 562 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-08-01 | 543 |
| Number of retired or separated participants receiving benefits | 2016-08-01 | 2 |
| Number of other retired or separated participants entitled to future benefits | 2016-08-01 | 0 |
| Total of all active and inactive participants | 2016-08-01 | 545 |
| 2015: T AND W TIRE GROUP INSURANCE PLAN 2015 401k membership |
|---|
| Total participants, beginning-of-year | 2015-08-01 | 604 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-08-01 | 562 |
| Number of retired or separated participants receiving benefits | 2015-08-01 | 2 |
| Number of other retired or separated participants entitled to future benefits | 2015-08-01 | 0 |
| Total of all active and inactive participants | 2015-08-01 | 564 |
| 2014: T AND W TIRE GROUP INSURANCE PLAN 2014 401k membership |
|---|
| Total participants, beginning-of-year | 2014-08-01 | 571 |
| Total number of active participants reported on line 7a of the Form 5500 | 2014-08-01 | 602 |
| Number of retired or separated participants receiving benefits | 2014-08-01 | 2 |
| Number of other retired or separated participants entitled to future benefits | 2014-08-01 | 0 |
| Total of all active and inactive participants | 2014-08-01 | 604 |
| 2013: T AND W TIRE GROUP INSURANCE PLAN 2013 401k membership |
|---|
| Total participants, beginning-of-year | 2013-08-01 | 310 |
| Total number of active participants reported on line 7a of the Form 5500 | 2013-08-01 | 258 |
| Number of retired or separated participants receiving benefits | 2013-08-01 | 3 |
| Number of other retired or separated participants entitled to future benefits | 2013-08-01 | 0 |
| Total of all active and inactive participants | 2013-08-01 | 261 |
| Total participants, beginning-of-year | 2013-07-01 | 310 |
| Total number of active participants reported on line 7a of the Form 5500 | 2013-07-01 | 306 |
| Number of retired or separated participants receiving benefits | 2013-07-01 | 4 |
| Number of other retired or separated participants entitled to future benefits | 2013-07-01 | 0 |
| Total of all active and inactive participants | 2013-07-01 | 310 |
| Total participants | 2013-07-01 | 310 |
| 2012: T AND W TIRE GROUP INSURANCE PLAN 2012 401k membership |
|---|
| Total participants, beginning-of-year | 2012-07-01 | 301 |
| Total number of active participants reported on line 7a of the Form 5500 | 2012-07-01 | 306 |
| Number of retired or separated participants receiving benefits | 2012-07-01 | 4 |
| Number of other retired or separated participants entitled to future benefits | 2012-07-01 | 0 |
| Total of all active and inactive participants | 2012-07-01 | 310 |
| Total participants | 2012-07-01 | 310 |
| 2011: T AND W TIRE GROUP INSURANCE PLAN 2011 401k membership |
|---|
| Total participants, beginning-of-year | 2011-07-01 | 274 |
| Total number of active participants reported on line 7a of the Form 5500 | 2011-07-01 | 301 |
| Number of retired or separated participants receiving benefits | 2011-07-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2011-07-01 | 0 |
| Total of all active and inactive participants | 2011-07-01 | 301 |
| Total participants | 2011-07-01 | 301 |
| 2009: T AND W TIRE GROUP INSURANCE PLAN 2009 401k membership |
|---|
| Total participants, beginning-of-year | 2009-07-01 | 241 |
| Total number of active participants reported on line 7a of the Form 5500 | 2009-07-01 | 232 |
| Number of retired or separated participants receiving benefits | 2009-07-01 | 2 |
| Number of other retired or separated participants entitled to future benefits | 2009-07-01 | 0 |
| Total of all active and inactive participants | 2009-07-01 | 234 |
| Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits | 2009-07-01 | 0 |
| Total participants | 2009-07-01 | 234 |
| 2022: T AND W TIRE GROUP INSURANCE PLAN 2022 form 5500 responses |
|---|
| 2022-08-01 | Type of plan entity | Single employer plan |
| 2022-08-01 | Plan funding arrangement – Insurance | Yes |
| 2022-08-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2022-08-01 | Plan benefit arrangement – Insurance | Yes |
| 2022-08-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2021: T AND W TIRE GROUP INSURANCE PLAN 2021 form 5500 responses |
|---|
| 2021-08-01 | Type of plan entity | Single employer plan |
| 2021-08-01 | Plan funding arrangement – Insurance | Yes |
| 2021-08-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2021-08-01 | Plan benefit arrangement – Insurance | Yes |
| 2021-08-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2020: T AND W TIRE GROUP INSURANCE PLAN 2020 form 5500 responses |
|---|
| 2020-08-01 | Type of plan entity | Single employer plan |
| 2020-08-01 | Plan funding arrangement – Insurance | Yes |
| 2020-08-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2020-08-01 | Plan benefit arrangement – Insurance | Yes |
| 2020-08-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2019: T AND W TIRE GROUP INSURANCE PLAN 2019 form 5500 responses |
|---|
| 2019-08-01 | Type of plan entity | Single employer plan |
| 2019-08-01 | Plan funding arrangement – Insurance | Yes |
| 2019-08-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2019-08-01 | Plan benefit arrangement – Insurance | Yes |
| 2019-08-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2018: T AND W TIRE GROUP INSURANCE PLAN 2018 form 5500 responses |
|---|
| 2018-08-01 | Type of plan entity | Single employer plan |
| 2018-08-01 | Plan funding arrangement – Insurance | Yes |
| 2018-08-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2018-08-01 | Plan benefit arrangement – Insurance | Yes |
| 2018-08-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2017: T AND W TIRE GROUP INSURANCE PLAN 2017 form 5500 responses |
|---|
| 2017-08-01 | Type of plan entity | Single employer plan |
| 2017-08-01 | Plan funding arrangement – Insurance | Yes |
| 2017-08-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2017-08-01 | Plan benefit arrangement – Insurance | Yes |
| 2017-08-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2016: T AND W TIRE GROUP INSURANCE PLAN 2016 form 5500 responses |
|---|
| 2016-08-01 | Type of plan entity | Single employer plan |
| 2016-08-01 | Submission has been amended | No |
| 2016-08-01 | This submission is the final filing | No |
| 2016-08-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2016-08-01 | Plan is a collectively bargained plan | No |
| 2016-08-01 | Plan funding arrangement – Insurance | Yes |
| 2016-08-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2016-08-01 | Plan benefit arrangement – Insurance | Yes |
| 2016-08-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2015: T AND W TIRE GROUP INSURANCE PLAN 2015 form 5500 responses |
|---|
| 2015-08-01 | Type of plan entity | Single employer plan |
| 2015-08-01 | Submission has been amended | No |
| 2015-08-01 | This submission is the final filing | No |
| 2015-08-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2015-08-01 | Plan is a collectively bargained plan | No |
| 2015-08-01 | Plan funding arrangement – Insurance | Yes |
| 2015-08-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2015-08-01 | Plan benefit arrangement – Insurance | Yes |
| 2015-08-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2014: T AND W TIRE GROUP INSURANCE PLAN 2014 form 5500 responses |
|---|
| 2014-08-01 | Type of plan entity | Single employer plan |
| 2014-08-01 | Submission has been amended | No |
| 2014-08-01 | This submission is the final filing | No |
| 2014-08-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2014-08-01 | Plan is a collectively bargained plan | No |
| 2014-08-01 | Plan funding arrangement – Insurance | Yes |
| 2014-08-01 | Plan benefit arrangement – Insurance | Yes |
| 2013: T AND W TIRE GROUP INSURANCE PLAN 2013 form 5500 responses |
|---|
| 2013-08-01 | Type of plan entity | Single employer plan |
| 2013-08-01 | Submission has been amended | No |
| 2013-08-01 | This submission is the final filing | No |
| 2013-08-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2013-08-01 | Plan is a collectively bargained plan | No |
| 2013-08-01 | Plan funding arrangement – Insurance | Yes |
| 2013-08-01 | Plan benefit arrangement – Insurance | Yes |
| 2013-07-01 | Type of plan entity | Single employer plan |
| 2013-07-01 | Submission has been amended | No |
| 2013-07-01 | This submission is the final filing | No |
| 2013-07-01 | This return/report is a short plan year return/report (less than 12 months) | Yes |
| 2013-07-01 | Plan is a collectively bargained plan | No |
| 2013-07-01 | Plan funding arrangement – Insurance | Yes |
| 2013-07-01 | Plan benefit arrangement – Insurance | Yes |
| 2012: T AND W TIRE GROUP INSURANCE PLAN 2012 form 5500 responses |
|---|
| 2012-07-01 | Type of plan entity | Single employer plan |
| 2012-07-01 | Submission has been amended | No |
| 2012-07-01 | This submission is the final filing | No |
| 2012-07-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2012-07-01 | Plan is a collectively bargained plan | No |
| 2012-07-01 | Plan funding arrangement – Insurance | Yes |
| 2012-07-01 | Plan benefit arrangement – Insurance | Yes |
| 2011: T AND W TIRE GROUP INSURANCE PLAN 2011 form 5500 responses |
|---|
| 2011-07-01 | Type of plan entity | Single employer plan |
| 2011-07-01 | Submission has been amended | No |
| 2011-07-01 | This submission is the final filing | No |
| 2011-07-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2011-07-01 | Plan is a collectively bargained plan | No |
| 2011-07-01 | Plan funding arrangement – Insurance | Yes |
| 2011-07-01 | Plan benefit arrangement – Insurance | Yes |
| 2009: T AND W TIRE GROUP INSURANCE PLAN 2009 form 5500 responses |
|---|
| 2009-07-01 | Type of plan entity | Single employer plan |
| 2009-07-01 | First time form 5500 has been submitted | Yes |
| 2009-07-01 | Submission has been amended | No |
| 2009-07-01 | This submission is the final filing | No |
| 2009-07-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2009-07-01 | Plan is a collectively bargained plan | No |
| 2009-07-01 | Plan funding arrangement – Insurance | Yes |
| 2009-07-01 | Plan benefit arrangement – Insurance | Yes |
| STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 ) |
| Policy contract number | 169388 |
| Policy instance | 2 |
| Insurance contract or identification number | 169388 | | Number of Individuals Covered | 495 | | Insurance policy start date | 2021-10-01 | | Insurance policy end date | 2022-09-30 | | Total amount of commissions paid to insurance broker | USD $23,708 | | Total amount of fees paid to insurance company | USD $11,869 | | 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 | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $23,708 | | Amount paid for insurance broker fees | 9495 | | 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 | 1585 |
| Policy instance | 1 |
| Insurance contract or identification number | 1585 | | Number of Individuals Covered | 406 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $7,699 | | 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 $7,699 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
| Policy contract number | TS05374608 |
| Policy instance | 2 |
| Insurance contract or identification number | TS05374608 | | Number of Individuals Covered | 1238 | | Insurance policy start date | 2020-10-01 | | Insurance policy end date | 2021-09-30 | | Total amount of commissions paid to insurance broker | USD $33,845 | | Total amount of fees paid to insurance company | USD $4,230 | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $186,150 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $25,271 | | Amount paid for insurance broker fees | 2374 | | Additional information about fees paid to insurance broker | SUPPLEMENTAL AND NON-MONETARY COMPENSATION, MARKETING FEES | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL (National Association of Insurance Commissioners NAIC id number: 53937 ) |
| Policy contract number | 1585 |
| Policy instance | 1 |
| Insurance contract or identification number | 1585 | | Number of Individuals Covered | 397 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $7,442 | | 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 $7,442 | | 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 | 1585 |
| Policy instance | 1 |
| Insurance contract or identification number | 1585 | | Number of Individuals Covered | 368 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $7,203 | | 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 $7,203 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
| Policy contract number | TS05374608 |
| Policy instance | 2 |
| Insurance contract or identification number | TS05374608 | | Number of Individuals Covered | 848 | | Insurance policy start date | 2019-10-01 | | Insurance policy end date | 2020-09-30 | | Total amount of commissions paid to insurance broker | USD $34,394 | | Total amount of fees paid to insurance company | USD $13,557 | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $175,803 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $34,394 | | Amount paid for insurance broker fees | 8799 | | Additional information about fees paid to insurance broker | ADMINISTRATION FEES | | Insurance broker organization code? | 5 |
|
| DELTA DENTAL (National Association of Insurance Commissioners NAIC id number: 53937 ) |
| Policy contract number | 1585 |
| Policy instance | 1 |
| Insurance contract or identification number | 1585 | | Number of Individuals Covered | 405 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $7,994 | | 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 $7,994 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
| Policy contract number | 5374608 |
| Policy instance | 2 |
| Insurance contract or identification number | 5374608 | | Number of Individuals Covered | 918 | | Insurance policy start date | 2018-10-01 | | Insurance policy end date | 2019-09-30 | | Total amount of commissions paid to insurance broker | USD $36,097 | | Total amount of fees paid to insurance company | USD $16,949 | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $184,461 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $36,097 | | Amount paid for insurance broker fees | 9234 | | Additional information about fees paid to insurance broker | ADMINISTRATION FEES | | Insurance broker organization code? | 5 |
|
| DELTA DENTAL (National Association of Insurance Commissioners NAIC id number: 53937 ) |
| Policy contract number | 1585 |
| Policy instance | 2 |
| Insurance contract or identification number | 1585 | | Number of Individuals Covered | 421 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $8,284 | | 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 $4,818 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 ) |
| Policy contract number | F020280 |
| Policy instance | 3 |
| Insurance contract or identification number | F020280 | | Number of Individuals Covered | 548 | | Insurance policy start date | 2017-10-01 | | Insurance policy end date | 2018-09-30 | | Total amount of commissions paid to insurance broker | USD $17,012 | | Total amount of fees paid to insurance company | USD $4 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $113,782 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $9,881 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 30060941 |
| Policy instance | 1 |
| Insurance contract or identification number | 30060941 | | Number of Individuals Covered | 401 | | Insurance policy start date | 2017-10-01 | | Insurance policy end date | 2018-09-30 | | Total amount of commissions paid to insurance broker | USD $2,023 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $60,784 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,507 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 30060941 |
| Policy instance | 1 |
| Insurance contract or identification number | 30060941 | | Number of Individuals Covered | 222 | | Insurance policy start date | 2016-10-01 | | Insurance policy end date | 2017-09-30 | | Total amount of commissions paid to insurance broker | USD $1,498 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $33,990 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $1,498 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | STRATEGIC EMPLOYE BENEFIT SERVICES |
|
| DELTA DENTAL (National Association of Insurance Commissioners NAIC id number: 53937 ) |
| Policy contract number | 1585 |
| Policy instance | 2 |
| Insurance contract or identification number | 1585 | | Number of Individuals Covered | 415 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $5,117 | | 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 $5,117 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | STRATEGIC EMPLOYEE BENEFIT SERVICES |
|
| DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 ) |
| Policy contract number | F020280 |
| Policy instance | 3 |
| Insurance contract or identification number | F020280 | | Number of Individuals Covered | 287 | | Insurance policy start date | 2016-10-01 | | Insurance policy end date | 2017-09-30 | | Total amount of commissions paid to insurance broker | USD $9,255 | | Total amount of fees paid to insurance company | USD $3,903 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $61,442 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $9,255 | | Amount paid for insurance broker fees | 3903 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | STRATEGIC EMPLOYE BENEFIT SERVICES |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 95478 ) |
| Policy contract number | 30060941 |
| Policy instance | 3 |
| Insurance contract or identification number | 30060941 | | Number of Individuals Covered | 210 | | Insurance policy start date | 2015-10-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $643 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | 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 $7,851 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $643 | | Insurance broker organization code? | 3 | | Insurance broker name | STRATEGIC EMPLOYEE BENEFIT SERVICES |
|
| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
| Policy contract number | KM05993956 |
| Policy instance | 1 |
| Insurance contract or identification number | KM05993956 | | Number of Individuals Covered | 1025 | | Insurance policy start date | 2015-08-01 | | Insurance policy end date | 2015-09-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $32,414 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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| DELTA DENTAL (National Association of Insurance Commissioners NAIC id number: 53937 ) |
| Policy contract number | 1585 |
| Policy instance | 2 |
| Insurance contract or identification number | 1585 | | Number of Individuals Covered | 240 | | Insurance policy start date | 2015-10-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $908 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | 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 $908 | | Insurance broker organization code? | 3 | | Insurance broker name | STRATEGIC EMPLOYEE BENEFIT SERVICES |
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| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
| Policy contract number | KM05993956 |
| Policy instance | 3 |
| Insurance contract or identification number | KM05993956 | | Number of Individuals Covered | 1011 | | Insurance policy start date | 2014-08-01 | | Insurance policy end date | 2015-07-31 | | Total amount of commissions paid to insurance broker | USD $1,036 | | Total amount of fees paid to insurance company | USD $376 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $194,325 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $956 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 376 | | Additional information about fees paid to insurance broker | SUPPLEMENTAL COMPENSATION | | Insurance broker name | MASCHINO HUDELSON AND ASSOCIATES |
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| AETNA HEALTH INC (National Association of Insurance Commissioners NAIC id number: 95757 ) |
| Policy contract number | 849495HNO |
| Policy instance | 2 |
| Insurance contract or identification number | 849495HNO | | Number of Individuals Covered | 414 | | Insurance policy start date | 2014-08-01 | | Insurance policy end date | 2014-09-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $17,790 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $287,194 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 17790 | | Additional information about fees paid to insurance broker | 2013/2014 MM P3 BONUS | | Insurance broker organization code? | 3 | | Insurance broker name | MASCHINO HUDELSON AND ASSOCIATES |
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| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 849495 |
| Policy instance | 1 |
| Insurance contract or identification number | 849495 | | Number of Individuals Covered | 188 | | Insurance policy start date | 2014-08-01 | | Insurance policy end date | 2014-09-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $153,577 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
| Policy contract number | KM05993956 |
| Policy instance | 3 |
| Insurance contract or identification number | KM05993956 | | Number of Individuals Covered | 963 | | Insurance policy start date | 2013-08-01 | | Insurance policy end date | 2014-07-31 | | Total amount of commissions paid to insurance broker | USD $17,176 | | Total amount of fees paid to insurance company | USD $6,139 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $178,192 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $16,569 | | Amount paid for insurance broker fees | 6139 | | Additional information about fees paid to insurance broker | SUPPLEMENTAL COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | ROGER HICKS AND ASSOC. GROUP INS. |
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| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 849495 |
| Policy instance | 1 |
| Insurance contract or identification number | 849495 | | Number of Individuals Covered | 176 | | Insurance policy start date | 2013-08-01 | | Insurance policy end date | 2014-07-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $20,722 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $573,762 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 20722 | | Additional information about fees paid to insurance broker | DIRECT COMPENSATION INDIRECT COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | MASCHINO HUDELSON AND ASSOCIATES |
|
| AETNA HEALTH INC (National Association of Insurance Commissioners NAIC id number: 95757 ) |
| Policy contract number | 849495HNO |
| Policy instance | 2 |
| Insurance contract or identification number | 849495HNO | | Number of Individuals Covered | 395 | | Insurance policy start date | 2013-08-01 | | Insurance policy end date | 2014-07-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $42,359 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $1,177,358 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 42359 | | Additional information about fees paid to insurance broker | DIRECT COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | MASCHINO HUDELSON AND ASSOCIATES |
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| BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 ) |
| Policy contract number | Y00037 |
| Policy instance | 3 |
| Insurance contract or identification number | Y00037 | | Number of Individuals Covered | 590 | | Insurance policy start date | 2013-07-01 | | Insurance policy end date | 2013-07-31 | | Total amount of commissions paid to insurance broker | USD $4,521 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $150,702 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,521 | | Insurance broker organization code? | 3 | | Insurance broker name | ROGER HICKS & ASSOCIATES |
|
| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
| Policy contract number | KM05993956 |
| Policy instance | 1 |
| Insurance contract or identification number | KM05993956 | | Number of Individuals Covered | 306 | | Insurance policy start date | 2013-07-01 | | Insurance policy end date | 2013-07-31 | | Total amount of commissions paid to insurance broker | USD $234 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | AD&D | | 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 $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 $234 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | ROGER HICKS AND ASSOCIATES GROUP IN |
|
| DELTA DENTAL (National Association of Insurance Commissioners NAIC id number: 53937 ) |
| Policy contract number | 1585 |
| Policy instance | 2 |
| Insurance contract or identification number | 1585 | | Number of Individuals Covered | 306 | | Insurance policy start date | 2013-07-01 | | Insurance policy end date | 2013-07-31 | | Total amount of commissions paid to insurance broker | USD $669 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | 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 $669 | | Insurance broker organization code? | 3 | | Insurance broker name | ROGER HICKS & ASSOCIATES GROUP INSU |
|
| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
| Policy contract number | KM05993956 |
| Policy instance | 1 |
| Insurance contract or identification number | KM05993956 | | Number of Individuals Covered | 306 | | Insurance policy start date | 2012-07-01 | | Insurance policy end date | 2013-06-30 | | Total amount of commissions paid to insurance broker | USD $973 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | AD&D | | 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 $9,563 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $973 | | Insurance broker organization code? | 3 | | Insurance broker name | ROGER HICKS AND ASSOCIATES GROUP IN |
|
| BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 ) |
| Policy contract number | Y00037 |
| Policy instance | 3 |
| Insurance contract or identification number | Y00037 | | Number of Individuals Covered | 553 | | Insurance policy start date | 2012-07-01 | | Insurance policy end date | 2013-06-30 | | Total amount of commissions paid to insurance broker | USD $88,844 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $1,776,289 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $88,844 | | Amount paid for insurance broker fees | 2550 | | Additional information about fees paid to insurance broker | SPECIAL PROGRAMS | | Insurance broker organization code? | 3 | | Insurance broker name | ROGER HICKS & ASSOCIATES GROUP INSU |
|
| DELTA DENTAL (National Association of Insurance Commissioners NAIC id number: 53937 ) |
| Policy contract number | 1585 |
| Policy instance | 2 |
| Insurance contract or identification number | 1585 | | Number of Individuals Covered | 305 | | Insurance policy start date | 2012-07-01 | | Insurance policy end date | 2013-06-30 | | Total amount of commissions paid to insurance broker | USD $7,069 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | 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 $7,069 | | Insurance broker organization code? | 3 | | Insurance broker name | ROGER HICKS & ASSOCIATES GROUP INSU |
|
| DELTA DENTAL (National Association of Insurance Commissioners NAIC id number: 53937 ) |
| Policy contract number | 1585 |
| Policy instance | 3 |
| Insurance contract or identification number | 1585 | | Number of Individuals Covered | 308 | | Insurance policy start date | 2011-07-01 | | Insurance policy end date | 2012-06-30 | | Total amount of commissions paid to insurance broker | USD $7,582 | | 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 |
|
| BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 ) |
| Policy contract number | Y00037 |
| Policy instance | 2 |
| Insurance contract or identification number | Y00037 | | Number of Individuals Covered | 544 | | Insurance policy start date | 2011-07-01 | | Insurance policy end date | 2012-06-30 | | Total amount of commissions paid to insurance broker | USD $93,269 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,865,378 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
| Policy contract number | 692953G |
| Policy instance | 1 |
| Insurance contract or identification number | 692953G | | Number of Individuals Covered | 301 | | Insurance policy start date | 2011-07-01 | | Insurance policy end date | 2012-06-30 | | Total amount of commissions paid to insurance broker | USD $2,432 | | 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 | A D & D | | Welfare Benefit Premiums Paid to Carrier | USD $15,393 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 ) |
| Policy contract number | Y00037 |
| Policy instance | 2 |
| Insurance contract or identification number | Y00037 | | Number of Individuals Covered | 519 | | Insurance policy start date | 2010-07-01 | | Insurance policy end date | 2011-06-30 | | Total amount of commissions paid to insurance broker | USD $83,653 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,680,762 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
| Policy contract number | 692953G |
| Policy instance | 1 |
| Insurance contract or identification number | 692953G | | Number of Individuals Covered | 267 | | Insurance policy start date | 2010-07-01 | | Insurance policy end date | 2011-06-30 | | Total amount of commissions paid to insurance broker | USD $2,297 | | 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 | A D & D | | Welfare Benefit Premiums Paid to Carrier | USD $12,429 | | 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 | 1585 |
| Policy instance | 3 |
| Insurance contract or identification number | 1585 | | Number of Individuals Covered | 247 | | Insurance policy start date | 2010-07-01 | | Insurance policy end date | 2011-06-30 | | Total amount of commissions paid to insurance broker | USD $5,755 | | 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 |
|
