HAPPY STATE BANK has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan HAPPY STATE BANK SECTION 125 PREMIUM PLAN
| Measure | Date | Value |
|---|
| 2021: HAPPY STATE BANK SECTION 125 PREMIUM PLAN 2021 401k membership |
|---|
| Total participants, beginning-of-year | 2021-01-01 | 785 |
| Total number of active participants reported on line 7a of the Form 5500 | 2021-01-01 | 722 |
| Number of retired or separated participants receiving benefits | 2021-01-01 | 6 |
| Number of other retired or separated participants entitled to future benefits | 2021-01-01 | 0 |
| Total of all active and inactive participants | 2021-01-01 | 728 |
| 2020: HAPPY STATE BANK SECTION 125 PREMIUM PLAN 2020 401k membership |
|---|
| Total participants, beginning-of-year | 2020-01-01 | 633 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-01-01 | 785 |
| Total of all active and inactive participants | 2020-01-01 | 785 |
| 2019: HAPPY STATE BANK SECTION 125 PREMIUM PLAN 2019 401k membership |
|---|
| Total participants, beginning-of-year | 2019-01-01 | 630 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-01-01 | 633 |
| Total of all active and inactive participants | 2019-01-01 | 633 |
| 2018: HAPPY STATE BANK SECTION 125 PREMIUM PLAN 2018 401k membership |
|---|
| Total participants, beginning-of-year | 2018-01-01 | 595 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-01-01 | 630 |
| Total of all active and inactive participants | 2018-01-01 | 630 |
| 2017: HAPPY STATE BANK SECTION 125 PREMIUM PLAN 2017 401k membership |
|---|
| Total participants, beginning-of-year | 2017-01-01 | 574 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-01-01 | 595 |
| Total of all active and inactive participants | 2017-01-01 | 595 |
| 2016: HAPPY STATE BANK SECTION 125 PREMIUM PLAN 2016 401k membership |
|---|
| Total participants, beginning-of-year | 2016-01-01 | 543 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-01-01 | 574 |
| Total of all active and inactive participants | 2016-01-01 | 574 |
| Total participants | 2016-01-01 | 574 |
| 2015: HAPPY STATE BANK SECTION 125 PREMIUM PLAN 2015 401k membership |
|---|
| Total participants, beginning-of-year | 2015-01-01 | 514 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-01-01 | 543 |
| Total of all active and inactive participants | 2015-01-01 | 543 |
| Total participants | 2015-01-01 | 0 |
| 2014: HAPPY STATE BANK SECTION 125 PREMIUM PLAN 2014 401k membership |
|---|
| Total participants, beginning-of-year | 2014-01-01 | 506 |
| Total number of active participants reported on line 7a of the Form 5500 | 2014-01-01 | 514 |
| Total of all active and inactive participants | 2014-01-01 | 514 |
| Total participants | 2014-01-01 | 0 |
| 2012: HAPPY STATE BANK SECTION 125 PREMIUM PLAN 2012 401k membership |
|---|
| Total participants, beginning-of-year | 2012-01-01 | 412 |
| Total number of active participants reported on line 7a of the Form 5500 | 2012-01-01 | 461 |
| Total of all active and inactive participants | 2012-01-01 | 461 |
| Total participants | 2012-01-01 | 0 |
| 2011: HAPPY STATE BANK SECTION 125 PREMIUM PLAN 2011 401k membership |
|---|
| Total participants, beginning-of-year | 2011-01-01 | 370 |
| Total number of active participants reported on line 7a of the Form 5500 | 2011-01-01 | 412 |
| Total of all active and inactive participants | 2011-01-01 | 412 |
| Total participants | 2011-01-01 | 412 |
| 2009: HAPPY STATE BANK SECTION 125 PREMIUM PLAN 2009 401k membership |
|---|
| Total participants, beginning-of-year | 2009-01-01 | 255 |
| Total number of active participants reported on line 7a of the Form 5500 | 2009-01-01 | 301 |
| Total of all active and inactive participants | 2009-01-01 | 301 |
| Total participants | 2009-01-01 | 301 |
| 2021: HAPPY STATE BANK SECTION 125 PREMIUM PLAN 2021 form 5500 responses |
|---|
| 2021-01-01 | Type of plan entity | Single employer plan |
| 2021-01-01 | Submission has been amended | No |
| 2021-01-01 | This submission is the final filing | No |
| 2021-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2021-01-01 | Plan is a collectively bargained plan | No |
| 2021-01-01 | Plan funding arrangement – Insurance | Yes |
| 2021-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2021-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2021-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2020: HAPPY STATE BANK SECTION 125 PREMIUM PLAN 2020 form 5500 responses |
|---|
| 2020-01-01 | Type of plan entity | Single employer plan |
| 2020-01-01 | Plan funding arrangement – Insurance | Yes |
| 2020-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2019: HAPPY STATE BANK SECTION 125 PREMIUM PLAN 2019 form 5500 responses |
|---|
| 2019-01-01 | Type of plan entity | Single employer plan |
| 2019-01-01 | Plan funding arrangement – Insurance | Yes |
| 2019-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2018: HAPPY STATE BANK SECTION 125 PREMIUM PLAN 2018 form 5500 responses |
|---|
| 2018-01-01 | Type of plan entity | Single employer plan |
| 2018-01-01 | Plan funding arrangement – Insurance | Yes |
| 2018-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2017: HAPPY STATE BANK SECTION 125 PREMIUM PLAN 2017 form 5500 responses |
|---|
| 2017-01-01 | Type of plan entity | Single employer plan |
| 2017-01-01 | Plan funding arrangement – Insurance | Yes |
| 2017-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2016: HAPPY STATE BANK SECTION 125 PREMIUM PLAN 2016 form 5500 responses |
|---|
| 2016-01-01 | Type of plan entity | Single employer plan |
| 2016-01-01 | Plan funding arrangement – Insurance | Yes |
| 2016-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2015: HAPPY STATE BANK SECTION 125 PREMIUM PLAN 2015 form 5500 responses |
|---|
| 2015-01-01 | Type of plan entity | Single employer plan |
| 2015-01-01 | Plan funding arrangement – Insurance | Yes |
| 2015-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2014: HAPPY STATE BANK SECTION 125 PREMIUM PLAN 2014 form 5500 responses |
|---|
| 2014-01-01 | Type of plan entity | Single employer plan |
| 2014-01-01 | Plan funding arrangement – Insurance | Yes |
| 2014-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2012: HAPPY STATE BANK SECTION 125 PREMIUM PLAN 2012 form 5500 responses |
|---|
| 2012-01-01 | Type of plan entity | Single employer plan |
| 2012-01-01 | Plan funding arrangement – Insurance | Yes |
| 2012-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2011: HAPPY STATE BANK SECTION 125 PREMIUM PLAN 2011 form 5500 responses |
|---|
| 2011-01-01 | Type of plan entity | Single employer plan |
| 2011-01-01 | Plan funding arrangement – Insurance | Yes |
| 2011-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2009: HAPPY STATE BANK SECTION 125 PREMIUM PLAN 2009 form 5500 responses |
|---|
| 2009-01-01 | Type of plan entity | Single employer plan |
| 2009-01-01 | Plan funding arrangement – Insurance | Yes |
| 2009-01-01 | Plan benefit arrangement – Insurance | Yes |
| AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 ) |
| Policy contract number | 010-034596 |
| Policy instance | 1 |
| Insurance contract or identification number | 010-034596 | | Number of Individuals Covered | 1665 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $77,477 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $774,775 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $77,477 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 ) |
| Policy contract number | 010-034596 |
| Policy instance | 1 |
| Insurance contract or identification number | 010-034596 | | Number of Individuals Covered | 1727 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $64,705 | | Total amount of fees paid to insurance company | USD $345 | | Dental Insurance Welfare Benefit | Yes | | Vision 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 $62,211 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 345 |
|
| BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 ) |
| Policy contract number | 108609 |
| Policy instance | 2 |
| Insurance contract or identification number | 108609 | | Number of Individuals Covered | 1277 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $153,537 | | Total amount of fees paid to insurance company | USD $1,848 | | Health 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 $159,158 | | Amount paid for insurance broker fees | 1848 | | Insurance broker organization code? | 3 |
|
| BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 ) |
| Policy contract number | 108609 |
| Policy instance | 2 |
| Insurance contract or identification number | 108609 | | Number of Individuals Covered | 1023 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $132,422 | | Total amount of fees paid to insurance company | USD $4,856 | | Health 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 $66,211 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 2428 | | Additional information about fees paid to insurance broker | SPECIAL PROGRAMS |
|
| AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 ) |
| Policy contract number | 010-034596 |
| Policy instance | 1 |
| Insurance contract or identification number | 010-034596 | | Number of Individuals Covered | 1392 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $54,525 | | Total amount of fees paid to insurance company | USD $3,786 | | Dental Insurance Welfare Benefit | Yes | | Vision 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 $27,262 | | Amount paid for insurance broker fees | 2226 | | Insurance broker organization code? | 3 |
|
| AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 ) |
| Policy contract number | 010-034596 |
| Policy instance | 1 |
| Insurance contract or identification number | 010-034596 | | Number of Individuals Covered | 1386 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $64,094 | | Total amount of fees paid to insurance company | USD $5,621 | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $32,047 | | Amount paid for insurance broker fees | 4092 | | Insurance broker organization code? | 3 |
|
| BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 ) |
| Policy contract number | 108609 |
| Policy instance | 2 |
| Insurance contract or identification number | 108609 | | Number of Individuals Covered | 1037 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $128,042 | | Total amount of fees paid to insurance company | USD $5,651 | | Health 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 $64,021 | | Amount paid for insurance broker fees | 3438 | | Insurance broker organization code? | 3 | | Additional information about fees paid to insurance broker | SPECIAL PROGRAMS |
|
| BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 ) |
| Policy contract number | 108609 |
| Policy instance | 2 |
| Insurance contract or identification number | 108609 | | Number of Individuals Covered | 965 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $153,364 | | Total amount of fees paid to insurance company | USD $5,832 | | Health 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 $76,682 | | Amount paid for insurance broker fees | 3331 | | Insurance broker organization code? | 3 | | Additional information about fees paid to insurance broker | SPECIAL PROGRAMS | | Insurance broker name | INSURORS OF TEXAS GENERAL AGENCY |
|
| AMERICAN GENERAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60488 ) |
| Policy contract number | 05P837 |
| Policy instance | 3 |
| Insurance contract or identification number | 05P837 | | Number of Individuals Covered | 591 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-05-31 | | Total amount of commissions paid to insurance broker | USD $24,338 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $12,169 | | Insurance broker organization code? | 3 | | Insurance broker name | MICHELLE FUQUA BRYSON |
|
| LIBERTY LIFE ASSURANCE COMPANY OF BOSTON (National Association of Insurance Commissioners NAIC id number: 65315 ) |
| Policy contract number | GD389046721501 |
| Policy instance | 4 |
| Insurance contract or identification number | GD389046721501 | | Number of Individuals Covered | 637 | | Insurance policy start date | 2017-06-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $31,049 | | Total amount of fees paid to insurance company | USD $3,097 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $15,524 | | Amount paid for insurance broker fees | 3097 | | Insurance broker organization code? | 3 | | Insurance broker name | UPSHAW INSURANCE AGENCY INC |
|
| AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 ) |
| Policy contract number | 010-034596 |
| Policy instance | 1 |
| Insurance contract or identification number | 010-034596 | | Number of Individuals Covered | 1309 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $53,472 | | Total amount of fees paid to insurance company | USD $2,995 | | Dental Insurance Welfare Benefit | Yes | | Vision 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 $26,736 | | Amount paid for insurance broker fees | 1999 | | Insurance broker organization code? | 3 | | Insurance broker name | UPSHAW INSURANCE AGENCY INC |
|
| AMERICAN GENERAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60488 ) |
| Policy contract number | 05P837 |
| Policy instance | 3 |
| Insurance contract or identification number | 05P837 | | Number of Individuals Covered | 898 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $54,234 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $27,117 | | Insurance broker organization code? | 3 | | Insurance broker name | UPSHAW INSURANCE AGENCY INC |
|
| BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 ) |
| Policy contract number | 108609 |
| Policy instance | 2 |
| Insurance contract or identification number | 108609 | | Number of Individuals Covered | 904 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $139,848 | | Total amount of fees paid to insurance company | USD $3,030 | | Health 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 $69,924 | | Amount paid for insurance broker fees | 3030 | | Additional information about fees paid to insurance broker | SPECIAL PROGRAMS | | Insurance broker organization code? | 3 | | Insurance broker name | INSURORS OF TEXAS GENERAL |
|
| AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 ) |
| Policy contract number | 010-034596 |
| Policy instance | 1 |
| Insurance contract or identification number | 010-034596 | | Number of Individuals Covered | 1194 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $45,280 | | Total amount of fees paid to insurance company | USD $3,983 | | Dental Insurance Welfare Benefit | Yes | | Vision 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 $22,640 | | Amount paid for insurance broker fees | 3360 | | Insurance broker organization code? | 3 | | Insurance broker name | MICHELLE FUQUA BRYSON |
|
| AMERICAN GENERAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60488 ) |
| Policy contract number | 05P837 |
| Policy instance | 3 |
| Insurance contract or identification number | 05P837 | | Number of Individuals Covered | 531 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $52,065 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $26,033 | | Insurance broker organization code? | 3 | | Insurance broker name | MICHELLE FUQUA BRYSON |
|
| BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 ) |
| Policy contract number | 108609 |
| Policy instance | 2 |
| Insurance contract or identification number | 108609 | | Number of Individuals Covered | 853 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $135,464 | | Total amount of fees paid to insurance company | USD $12,599 | | Health 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 $67,732 | | Amount paid for insurance broker fees | 2423 | | Additional information about fees paid to insurance broker | SPECIAL PROGRAMS | | Insurance broker organization code? | 3 | | Insurance broker name | INSURORS OF TEXAS GENERAL |
|
| AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 ) |
| Policy contract number | 010-034596 |
| Policy instance | 1 |
| Insurance contract or identification number | 010-034596 | | Number of Individuals Covered | 1130 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $43,806 | | Total amount of fees paid to insurance company | USD $5,062 | | Dental Insurance Welfare Benefit | Yes | | Vision 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 $21,903 | | Amount paid for insurance broker fees | 5062 | | Insurance broker organization code? | 3 | | Insurance broker name | MICHELLE FUQUA BRYSON |
|
| AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 ) |
| Policy contract number | 010-034596 |
| Policy instance | 2 |
| Insurance contract or identification number | 010-034596 | | Number of Individuals Covered | 1020 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $38,204 | | Total amount of fees paid to insurance company | USD $2,832 | | Dental Insurance Welfare Benefit | Yes | | Vision 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 $19,102 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 2832 | | Insurance broker name | UPSHAW INSURANCE AGENCY INC |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 743555 |
| Policy instance | 1 |
| Insurance contract or identification number | 743555 | | Number of Individuals Covered | 747 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $116,203 | | Total amount of fees paid to insurance company | USD $2,490 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $2,038,044 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $58,102 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 2490 | | Additional information about fees paid to insurance broker | BONUS | | Insurance broker name | UPSHAW INSURANCE AGENCY INC |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG0AC3D |
| Policy instance | 3 |
| Insurance contract or identification number | GLUG0AC3D | | Number of Individuals Covered | 432 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2012-01-01 | | Total amount of commissions paid to insurance broker | USD $4,066 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $23,704 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLTD0AC3D |
| Policy instance | 2 |
| Insurance contract or identification number | GLTD0AC3D | | Number of Individuals Covered | 432 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2012-01-01 | | Total amount of commissions paid to insurance broker | USD $3,946 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $23,011 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 ) |
| Policy contract number | 010-034596 |
| Policy instance | 1 |
| Insurance contract or identification number | 010-034596 | | Number of Individuals Covered | 910 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2011-12-31 | | Total amount of commissions paid to insurance broker | USD $29,336 | | Total amount of fees paid to insurance company | USD $3,181 | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GVTL0AC3D |
| Policy instance | 7 |
| Insurance contract or identification number | GVTL0AC3D | | Number of Individuals Covered | 206 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2012-01-01 | | Total amount of commissions paid to insurance broker | USD $11,491 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $66,610 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| SOUTHWEST LIFE AND HEALTH (National Association of Insurance Commissioners NAIC id number: 66117 ) |
| Policy contract number | P52T11 |
| Policy instance | 6 |
| Insurance contract or identification number | P52T11 | | Number of Individuals Covered | 407 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2012-01-01 | | Total amount of commissions paid to insurance broker | USD $69,050 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $3,015 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUG0AC3D |
| Policy instance | 4 |
| Insurance contract or identification number | GUG0AC3D | | Number of Individuals Covered | 432 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2012-01-01 | | Total amount of commissions paid to insurance broker | USD $8,405 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $49,015 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| SOUTHWEST LIFE AND HEALTH (National Association of Insurance Commissioners NAIC id number: 66117 ) |
| Policy contract number | P52T12 |
| Policy instance | 5 |
| Insurance contract or identification number | P52T12 | | Number of Individuals Covered | 243 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2012-01-01 | | Total amount of commissions paid to insurance broker | USD $23,326 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,778 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 ) |
| Policy contract number | 010-034596 |
| Policy instance | 1 |
| Insurance contract or identification number | 010-034596 | | Number of Individuals Covered | 809 | | Insurance policy start date | 2010-01-01 | | Insurance policy end date | 2010-12-31 | | Total amount of commissions paid to insurance broker | USD $26,884 | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLTD0AC3D |
| Policy instance | 2 |
| Insurance contract or identification number | GLTD0AC3D | | Number of Individuals Covered | 293 | | Insurance policy start date | 2010-01-01 | | Insurance policy end date | 2011-01-01 | | Total amount of commissions paid to insurance broker | USD $3,510 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $20,819 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG0AC3D |
| Policy instance | 3 |
| Insurance contract or identification number | GLUG0AC3D | | Number of Individuals Covered | 293 | | Insurance policy start date | 2010-01-01 | | Insurance policy end date | 2011-01-01 | | Total amount of commissions paid to insurance broker | USD $3,610 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $21,495 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUG0AC3D |
| Policy instance | 4 |
| Insurance contract or identification number | GUG0AC3D | | Number of Individuals Covered | 293 | | Insurance policy start date | 2010-01-01 | | Insurance policy end date | 2011-01-01 | | Total amount of commissions paid to insurance broker | USD $7,484 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $44,347 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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| SOUTHWEST LIFE AND HEALTH (National Association of Insurance Commissioners NAIC id number: 66117 ) |
| Policy contract number | P52T12 |
| Policy instance | 5 |
| Insurance contract or identification number | P52T12 | | Number of Individuals Covered | 171 | | Insurance policy start date | 2010-01-01 | | Insurance policy end date | 2010-12-31 | | Total amount of commissions paid to insurance broker | USD $17,324 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,629 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GVTL0AC3D |
| Policy instance | 7 |
| Insurance contract or identification number | GVTL0AC3D | | Number of Individuals Covered | 183 | | Insurance policy start date | 2010-01-01 | | Insurance policy end date | 2011-01-01 | | Total amount of commissions paid to insurance broker | USD $10,800 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $63,144 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| SOUTHWEST LIFE AND HEALTH (National Association of Insurance Commissioners NAIC id number: 66117 ) |
| Policy contract number | P52T11 |
| Policy instance | 6 |
| Insurance contract or identification number | P52T11 | | Number of Individuals Covered | 392 | | Insurance policy start date | 2010-01-01 | | Insurance policy end date | 2010-12-31 | | Total amount of commissions paid to insurance broker | USD $62,464 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $2,762 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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