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TULSA SPINE AND SPECIALTY HOSPITAL WELFARE BENEFITS PLAN 401k Plan overview

Plan NameTULSA SPINE AND SPECIALTY HOSPITAL WELFARE BENEFITS PLAN
Plan identification number 501

TULSA SPINE AND SPECIALTY HOSPITAL WELFARE BENEFITS PLAN Benefits

401k Plan TypeWelfare Benefit
Plan Features/Benefits
  • Health (other than dental or vision)
  • Life insurance
  • Dental
  • Temporary disability (accident and sickness)
  • Long-term disability cover
  • Death benefits (include travel accident but not life insurance)

401k Sponsoring company profile

TULSA SPINE AND SPECIALTY HOSPITAL, LLC has sponsored the creation of one or more 401k plans.

Company Name:TULSA SPINE AND SPECIALTY HOSPITAL, LLC
Employer identification number (EIN):731600601
NAIC Classification:622000
NAIC Description: Hospitals

Form 5500 Filing Information

Submission information for form 5500 for 401k plan TULSA SPINE AND SPECIALTY HOSPITAL WELFARE BENEFITS PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5012015-01-01TERRY WOODBECK
5012015-01-01TERRY WOODBECK
5012014-01-01TERRY WOODBECK
5012013-01-01TERRY WOODBECK
5012012-01-01TERRY WOODBECK
5012011-01-01TERRY WOODBECK
5012009-01-01TERRY WOODBECK
5012008-01-01TERRY WOODBECK
5012007-01-01TERRY WOODBECK
5012006-01-01TERRY WOODBECK
5012005-01-01TERRY WOODBECK

Plan Statistics for TULSA SPINE AND SPECIALTY HOSPITAL WELFARE BENEFITS PLAN

401k plan membership statisitcs for TULSA SPINE AND SPECIALTY HOSPITAL WELFARE BENEFITS PLAN

Measure Date Value
2015: TULSA SPINE AND SPECIALTY HOSPITAL WELFARE BENEFITS PLAN 2015 401k membership
Total participants, beginning-of-year2015-01-01225
Total number of active participants reported on line 7a of the Form 55002015-01-01237
Number of retired or separated participants receiving benefits2015-01-011
Number of other retired or separated participants entitled to future benefits2015-01-010
Total of all active and inactive participants2015-01-01238
2014: TULSA SPINE AND SPECIALTY HOSPITAL WELFARE BENEFITS PLAN 2014 401k membership
Total participants, beginning-of-year2014-01-01234
Total number of active participants reported on line 7a of the Form 55002014-01-01222
Number of retired or separated participants receiving benefits2014-01-013
Number of other retired or separated participants entitled to future benefits2014-01-010
Total of all active and inactive participants2014-01-01225
2013: TULSA SPINE AND SPECIALTY HOSPITAL WELFARE BENEFITS PLAN 2013 401k membership
Total participants, beginning-of-year2013-01-01235
Total number of active participants reported on line 7a of the Form 55002013-01-01230
Number of retired or separated participants receiving benefits2013-01-014
Number of other retired or separated participants entitled to future benefits2013-01-010
Total of all active and inactive participants2013-01-01234
2012: TULSA SPINE AND SPECIALTY HOSPITAL WELFARE BENEFITS PLAN 2012 401k membership
Total participants, beginning-of-year2012-01-01272
Total number of active participants reported on line 7a of the Form 55002012-01-01233
Number of retired or separated participants receiving benefits2012-01-012
Number of other retired or separated participants entitled to future benefits2012-01-010
Total of all active and inactive participants2012-01-01235
2011: TULSA SPINE AND SPECIALTY HOSPITAL WELFARE BENEFITS PLAN 2011 401k membership
Total participants, beginning-of-year2011-01-01248
Total number of active participants reported on line 7a of the Form 55002011-01-01272
Number of retired or separated participants receiving benefits2011-01-010
Number of other retired or separated participants entitled to future benefits2011-01-010
Total of all active and inactive participants2011-01-01272
2009: TULSA SPINE AND SPECIALTY HOSPITAL WELFARE BENEFITS PLAN 2009 401k membership
Total participants, beginning-of-year2009-01-01178
Total number of active participants reported on line 7a of the Form 55002009-01-01228
Number of retired or separated participants receiving benefits2009-01-010
Number of other retired or separated participants entitled to future benefits2009-01-010
Total of all active and inactive participants2009-01-01228
2008: TULSA SPINE AND SPECIALTY HOSPITAL WELFARE BENEFITS PLAN 2008 401k membership
Total participants, beginning-of-year2008-01-01146
Total number of active participants reported on line 7a of the Form 55002008-01-01178
Number of retired or separated participants receiving benefits2008-01-010
Number of other retired or separated participants entitled to future benefits2008-01-010
Total of all active and inactive participants2008-01-01178
2007: TULSA SPINE AND SPECIALTY HOSPITAL WELFARE BENEFITS PLAN 2007 401k membership
Total participants, beginning-of-year2007-01-01137
Total number of active participants reported on line 7a of the Form 55002007-01-01146
Number of retired or separated participants receiving benefits2007-01-010
Number of other retired or separated participants entitled to future benefits2007-01-010
Total of all active and inactive participants2007-01-01146
2006: TULSA SPINE AND SPECIALTY HOSPITAL WELFARE BENEFITS PLAN 2006 401k membership
Total participants, beginning-of-year2006-01-01121
Total number of active participants reported on line 7a of the Form 55002006-01-01137
Number of retired or separated participants receiving benefits2006-01-010
Number of other retired or separated participants entitled to future benefits2006-01-010
Total of all active and inactive participants2006-01-01137
2005: TULSA SPINE AND SPECIALTY HOSPITAL WELFARE BENEFITS PLAN 2005 401k membership
Total participants, beginning-of-year2005-01-01110
Total number of active participants reported on line 7a of the Form 55002005-01-01121
Number of retired or separated participants receiving benefits2005-01-010
Number of other retired or separated participants entitled to future benefits2005-01-010
Total of all active and inactive participants2005-01-01121

Form 5500 Responses for TULSA SPINE AND SPECIALTY HOSPITAL WELFARE BENEFITS PLAN

2015: TULSA SPINE AND SPECIALTY HOSPITAL WELFARE BENEFITS PLAN 2015 form 5500 responses
2015-01-01Type of plan entitySingle employer plan
2015-01-01Submission has been amendedNo
2015-01-01This submission is the final filingNo
2015-01-01This return/report is a short plan year return/report (less than 12 months)No
2015-01-01Plan is a collectively bargained planNo
2015-01-01Plan funding arrangement – InsuranceYes
2015-01-01Plan funding arrangement – General assets of the sponsorYes
2015-01-01Plan benefit arrangement – InsuranceYes
2015-01-01Plan benefit arrangement – General assets of the sponsorYes
2014: TULSA SPINE AND SPECIALTY HOSPITAL WELFARE BENEFITS PLAN 2014 form 5500 responses
2014-01-01Type of plan entitySingle employer plan
2014-01-01Submission has been amendedNo
2014-01-01This submission is the final filingNo
2014-01-01This return/report is a short plan year return/report (less than 12 months)No
2014-01-01Plan is a collectively bargained planNo
2014-01-01Plan funding arrangement – InsuranceYes
2014-01-01Plan funding arrangement – General assets of the sponsorYes
2014-01-01Plan benefit arrangement – InsuranceYes
2014-01-01Plan benefit arrangement – General assets of the sponsorYes
2013: TULSA SPINE AND SPECIALTY HOSPITAL WELFARE BENEFITS PLAN 2013 form 5500 responses
2013-01-01Type of plan entitySingle employer plan
2013-01-01Submission has been amendedNo
2013-01-01This submission is the final filingNo
2013-01-01This return/report is a short plan year return/report (less than 12 months)No
2013-01-01Plan is a collectively bargained planNo
2013-01-01Plan funding arrangement – InsuranceYes
2013-01-01Plan funding arrangement – General assets of the sponsorYes
2013-01-01Plan benefit arrangement – InsuranceYes
2013-01-01Plan benefit arrangement – General assets of the sponsorYes
2012: TULSA SPINE AND SPECIALTY HOSPITAL WELFARE BENEFITS PLAN 2012 form 5500 responses
2012-01-01Type of plan entitySingle employer plan
2012-01-01Submission has been amendedNo
2012-01-01This submission is the final filingNo
2012-01-01This return/report is a short plan year return/report (less than 12 months)No
2012-01-01Plan is a collectively bargained planNo
2012-01-01Plan funding arrangement – InsuranceYes
2012-01-01Plan funding arrangement – General assets of the sponsorYes
2012-01-01Plan benefit arrangement – InsuranceYes
2012-01-01Plan benefit arrangement – General assets of the sponsorYes
2011: TULSA SPINE AND SPECIALTY HOSPITAL WELFARE BENEFITS PLAN 2011 form 5500 responses
2011-01-01Type of plan entitySingle employer plan
2011-01-01Submission has been amendedNo
2011-01-01This submission is the final filingNo
2011-01-01This return/report is a short plan year return/report (less than 12 months)No
2011-01-01Plan is a collectively bargained planNo
2011-01-01Plan funding arrangement – InsuranceYes
2011-01-01Plan funding arrangement – General assets of the sponsorYes
2011-01-01Plan benefit arrangement – InsuranceYes
2011-01-01Plan benefit arrangement – General assets of the sponsorYes
2009: TULSA SPINE AND SPECIALTY HOSPITAL WELFARE BENEFITS PLAN 2009 form 5500 responses
2009-01-01Type of plan entitySingle employer plan
2009-01-01Submission has been amendedNo
2009-01-01This submission is the final filingNo
2009-01-01This return/report is a short plan year return/report (less than 12 months)No
2009-01-01Plan is a collectively bargained planNo
2009-01-01Plan funding arrangement – InsuranceYes
2009-01-01Plan funding arrangement – General assets of the sponsorYes
2009-01-01Plan benefit arrangement – InsuranceYes
2009-01-01Plan benefit arrangement – General assets of the sponsorYes
2008: TULSA SPINE AND SPECIALTY HOSPITAL WELFARE BENEFITS PLAN 2008 form 5500 responses
2008-01-01Type of plan entitySingle employer plan
2008-01-01Submission has been amendedNo
2008-01-01This submission is the final filingNo
2008-01-01This return/report is a short plan year return/report (less than 12 months)No
2008-01-01Plan is a collectively bargained planNo
2008-01-01Plan funding arrangement – InsuranceYes
2008-01-01Plan funding arrangement – General assets of the sponsorYes
2008-01-01Plan benefit arrangement – InsuranceYes
2008-01-01Plan benefit arrangement – General assets of the sponsorYes
2007: TULSA SPINE AND SPECIALTY HOSPITAL WELFARE BENEFITS PLAN 2007 form 5500 responses
2007-01-01Type of plan entitySingle employer plan
2007-01-01Submission has been amendedNo
2007-01-01This submission is the final filingNo
2007-01-01This return/report is a short plan year return/report (less than 12 months)No
2007-01-01Plan is a collectively bargained planNo
2007-01-01Plan funding arrangement – InsuranceYes
2007-01-01Plan funding arrangement – General assets of the sponsorYes
2007-01-01Plan benefit arrangement – InsuranceYes
2007-01-01Plan benefit arrangement – General assets of the sponsorYes
2006: TULSA SPINE AND SPECIALTY HOSPITAL WELFARE BENEFITS PLAN 2006 form 5500 responses
2006-01-01Type of plan entitySingle employer plan
2006-01-01Submission has been amendedNo
2006-01-01This submission is the final filingNo
2006-01-01This return/report is a short plan year return/report (less than 12 months)No
2006-01-01Plan is a collectively bargained planNo
2006-01-01Plan funding arrangement – InsuranceYes
2006-01-01Plan funding arrangement – General assets of the sponsorYes
2006-01-01Plan benefit arrangement – InsuranceYes
2006-01-01Plan benefit arrangement – General assets of the sponsorYes
2005: TULSA SPINE AND SPECIALTY HOSPITAL WELFARE BENEFITS PLAN 2005 form 5500 responses
2005-01-01Type of plan entitySingle employer plan
2005-01-01First time form 5500 has been submittedYes
2005-01-01Submission has been amendedNo
2005-01-01This submission is the final filingNo
2005-01-01This return/report is a short plan year return/report (less than 12 months)No
2005-01-01Plan is a collectively bargained planNo
2005-01-01Plan funding arrangement – InsuranceYes
2005-01-01Plan funding arrangement – General assets of the sponsorYes
2005-01-01Plan benefit arrangement – InsuranceYes
2005-01-01Plan benefit arrangement – General assets of the sponsorYes

Insurance Providers Used on plan

DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 )
Policy contract number5597-00
Policy instance 2
Insurance contract or identification number5597-00
Number of Individuals Covered19
Insurance policy start date2015-01-01
Insurance policy end date2015-12-31
Total amount of commissions paid to insurance brokerUSD $2,727
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $22,774
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,727
Insurance broker organization code?3
Insurance broker nameTHE HOLMES ORGANISATION
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number03656
Policy instance 1
Insurance contract or identification number03656
Number of Individuals Covered237
Insurance policy start date2015-01-01
Insurance policy end date2015-12-31
Total amount of commissions paid to insurance brokerUSD $8,207
Total amount of fees paid to insurance companyUSD $68
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $54,715
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $8,207
Insurance broker organization code?3
Amount paid for insurance broker fees68
Additional information about fees paid to insurance brokerTHIRD PARTY ADMIN FEES
Insurance broker nameAXA ASSISTANCE, USA
DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 )
Policy contract number5597-00
Policy instance 2
Insurance contract or identification number5597-00
Number of Individuals Covered21
Insurance policy start date2014-01-01
Insurance policy end date2014-12-31
Total amount of commissions paid to insurance brokerUSD $2,871
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $24,276
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,871
Insurance broker organization code?3
Insurance broker nameTHE HOLMES ORGANISATION
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number03656
Policy instance 1
Insurance contract or identification number03656
Number of Individuals Covered222
Insurance policy start date2014-01-01
Insurance policy end date2014-12-31
Total amount of commissions paid to insurance brokerUSD $9,161
Total amount of fees paid to insurance companyUSD $89
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $61,073
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $9,161
Insurance broker organization code?3
Amount paid for insurance broker fees89
Additional information about fees paid to insurance brokerTHIRD PARTY ADMIN FEES
Insurance broker nameAXA ASSISTANCE, USA
DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 )
Policy contract number5597-00
Policy instance 2
Insurance contract or identification number5597-00
Number of Individuals Covered23
Insurance policy start date2013-01-01
Insurance policy end date2013-12-31
Total amount of commissions paid to insurance brokerUSD $3,015
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $26,520
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,015
Insurance broker organization code?3
Insurance broker nameTHE HOLMES ORGANISATION
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number03656
Policy instance 1
Insurance contract or identification number03656
Number of Individuals Covered230
Insurance policy start date2013-01-01
Insurance policy end date2013-12-31
Total amount of commissions paid to insurance brokerUSD $10,445
Total amount of fees paid to insurance companyUSD $1,539
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $69,630
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $10,445
Amount paid for insurance broker fees1439
Additional information about fees paid to insurance brokerSUPPLEMENTAL COMMISSIONS
Insurance broker organization code?3
Insurance broker nameAXA ASSISTANCE, USA
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number03656
Policy instance 1
Insurance contract or identification number03656
Number of Individuals Covered233
Insurance policy start date2012-01-01
Insurance policy end date2012-12-31
Total amount of commissions paid to insurance brokerUSD $11,098
Total amount of fees paid to insurance companyUSD $1,228
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $73,984
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $11,098
Amount paid for insurance broker fees1112
Additional information about fees paid to insurance brokerSUPPLEMENTAL COMMISSIONS
Insurance broker organization code?3
Insurance broker nameAXA ASSISTANCE, USA
DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 )
Policy contract number5597-00
Policy instance 2
Insurance contract or identification number5597-00
Number of Individuals Covered29
Insurance policy start date2012-01-01
Insurance policy end date2012-12-31
Total amount of commissions paid to insurance brokerUSD $4,594
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $30,564
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,594
Insurance broker organization code?3
Insurance broker nameTHE HOLMES ORGANISATION
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number03656
Policy instance 1
Insurance contract or identification number03656
Number of Individuals Covered272
Insurance policy start date2010-11-01
Insurance policy end date2011-10-31
Total amount of commissions paid to insurance brokerUSD $9,702
Total amount of fees paid to insurance companyUSD $934
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $64,677
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 )
Policy contract number5597-00
Policy instance 2
Insurance contract or identification number5597-00
Number of Individuals Covered34
Insurance policy start date2011-01-01
Insurance policy end date2011-12-31
Total amount of commissions paid to insurance brokerUSD $6,075
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $30,795
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number03656
Policy instance 3
Insurance contract or identification number03656
Number of Individuals Covered272
Insurance policy start date2011-11-01
Insurance policy end date2011-12-31
Total amount of commissions paid to insurance brokerUSD $2,105
Total amount of fees paid to insurance companyUSD $24
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $14,036
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 )
Policy contract number5597-00
Policy instance 2
Insurance contract or identification number5597-00
Number of Individuals Covered24
Insurance policy start date2010-01-01
Insurance policy end date2010-12-31
Total amount of commissions paid to insurance brokerUSD $3,716
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $24,096
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number03656
Policy instance 1
Insurance contract or identification number03656
Number of Individuals Covered248
Insurance policy start date2009-11-01
Insurance policy end date2010-10-31
Total amount of commissions paid to insurance brokerUSD $3,221
Total amount of fees paid to insurance companyUSD $569
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $21,472
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 )
Policy contract number5597-00
Policy instance 2
Insurance contract or identification number5597-00
Number of Individuals Covered14
Insurance policy start date2008-01-01
Insurance policy end date2008-12-31
Total amount of commissions paid to insurance brokerUSD $1,951
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $12,716
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,951
Insurance broker organization code?3
Insurance broker nameTHE HOLMES ORGANISATION
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number03656
Policy instance 1
Insurance contract or identification number03656
Number of Individuals Covered178
Insurance policy start date2007-11-01
Insurance policy end date2008-10-31
Total amount of commissions paid to insurance brokerUSD $2,020
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $13,466
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,020
Insurance broker organization code?3
Insurance broker nameTHE HOLMES ORGANISATION
DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 )
Policy contract number5597-00
Policy instance 2
Insurance contract or identification number5597-00
Number of Individuals Covered11
Insurance policy start date2007-01-01
Insurance policy end date2007-12-31
Total amount of commissions paid to insurance brokerUSD $1,676
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $11,045
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,676
Insurance broker organization code?3
Insurance broker nameTHE HOLMES ORGANISATION
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number03656
Policy instance 1
Insurance contract or identification number03656
Number of Individuals Covered146
Insurance policy start date2006-11-01
Insurance policy end date2007-10-31
Total amount of commissions paid to insurance brokerUSD $1,832
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $12,211
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,832
Insurance broker organization code?3
Insurance broker nameTHE HOLMES ORGANISATION
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number03656
Policy instance 1
Insurance contract or identification number03656
Number of Individuals Covered137
Insurance policy start date2005-11-01
Insurance policy end date2006-10-31
Total amount of commissions paid to insurance brokerUSD $1,533
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $10,219
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,533
Insurance broker organization code?3
Insurance broker nameTHE HOLMES ORGANISATION
MEMBER SERVICE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 88420 )
Policy contract number5597-00
Policy instance 2
Insurance contract or identification number5597-00
Number of Individuals Covered13
Insurance policy start date2006-01-01
Insurance policy end date2006-09-30
Total amount of commissions paid to insurance brokerUSD $1,250
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $10,442
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,250
Insurance broker organization code?3
Insurance broker nameTHE HOLMES ORGANISATION
DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 )
Policy contract number5597-00
Policy instance 3
Insurance contract or identification number5597-00
Number of Individuals Covered10
Insurance policy start date2006-10-01
Insurance policy end date2006-12-31
Total amount of commissions paid to insurance brokerUSD $376
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $2,366
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $376
Insurance broker organization code?3
Insurance broker nameTHE HOLMES ORGANISATION
MEMBER SERVICE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 88420 )
Policy contract number5597-00
Policy instance 2
Insurance contract or identification number5597-00
Number of Individuals Covered16
Insurance policy start date2005-01-01
Insurance policy end date2005-12-31
Total amount of commissions paid to insurance brokerUSD $4,482
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $16,332
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,482
Insurance broker organization code?3
Insurance broker nameTHE HOLMES ORGANISATION
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number03656
Policy instance 1
Insurance contract or identification number03656
Number of Individuals Covered121
Insurance policy start date2004-11-01
Insurance policy end date2005-10-31
Total amount of commissions paid to insurance brokerUSD $1,428
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $9,518
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,428
Insurance broker organization code?3
Insurance broker nameTHE HOLMES ORGANISATION

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