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FIRST COMMUNITY BANK HEALTH & WELFARE BENEFIT PLAN 401k Plan overview

Plan NameFIRST COMMUNITY BANK HEALTH & WELFARE BENEFIT PLAN
Plan identification number 501

FIRST COMMUNITY BANK HEALTH & WELFARE BENEFIT PLAN Benefits

401k Plan Type
Plan Features/Benefits

    401k Sponsoring company profile

    FIRST COMMUNITY BANK has sponsored the creation of one or more 401k plans.

    Company Name:FIRST COMMUNITY BANK
    Employer identification number (EIN):760024722
    NAIC Classification:522110
    NAIC Description:Commercial Banking

    Form 5500 Filing Information

    Submission information for form 5500 for 401k plan FIRST COMMUNITY BANK HEALTH & WELFARE BENEFIT PLAN

    Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
    5012020-04-01
    5012019-03-01
    5012018-03-01
    5012017-03-01SHEREE LEWIS
    5012016-03-01SHEREE LEWIS
    5012015-03-01SHEREE LEWIS
    5012014-03-01SHEREE LEWIS
    5012013-03-01SHEREE LEWIS
    5012012-03-01SHEREE LEWIS
    5012011-03-01SHEREE LEWIS
    5012010-03-01SHEREE LEWIS

    Plan Statistics for FIRST COMMUNITY BANK HEALTH & WELFARE BENEFIT PLAN

    401k plan membership statisitcs for FIRST COMMUNITY BANK HEALTH & WELFARE BENEFIT PLAN

    Measure Date Value
    2020
    Total participants, beginning-of-year2020-04-01262
    Total number of active participants reported on line 7a of the Form 55002020-04-01210
    Total of all active and inactive participants2020-04-01210
    Total participants2020-04-01210
    2019
    Total participants, beginning-of-year2019-03-01223
    Total number of active participants reported on line 7a of the Form 55002019-03-01362
    Total of all active and inactive participants2019-03-01362
    Total participants2019-03-01362
    2018
    Total participants, beginning-of-year2018-03-01147
    Total number of active participants reported on line 7a of the Form 55002018-03-01223
    Total of all active and inactive participants2018-03-01223
    Total participants2018-03-01223
    2017
    Total participants, beginning-of-year2017-03-01150
    Total number of active participants reported on line 7a of the Form 55002017-03-01147
    Total of all active and inactive participants2017-03-01147
    Total participants2017-03-01147
    2016
    Total participants, beginning-of-year2016-03-01213
    Total number of active participants reported on line 7a of the Form 55002016-03-01150
    Total of all active and inactive participants2016-03-01150
    Total participants2016-03-01150
    2015
    Total participants, beginning-of-year2015-03-01207
    Total number of active participants reported on line 7a of the Form 55002015-03-01213
    Total of all active and inactive participants2015-03-01213
    Total participants2015-03-010
    2014
    Total participants, beginning-of-year2014-03-01170
    Total number of active participants reported on line 7a of the Form 55002014-03-01207
    Total of all active and inactive participants2014-03-01207
    Total participants2014-03-01207
    2013
    Total participants, beginning-of-year2013-03-01168
    Total number of active participants reported on line 7a of the Form 55002013-03-01170
    Total of all active and inactive participants2013-03-01170
    Total participants2013-03-01170
    2012
    Total participants, beginning-of-year2012-03-01104
    Total number of active participants reported on line 7a of the Form 55002012-03-01168
    Total of all active and inactive participants2012-03-01168
    Total participants2012-03-01168
    2011
    Total participants, beginning-of-year2011-03-01101
    Total number of active participants reported on line 7a of the Form 55002011-03-01104
    Total of all active and inactive participants2011-03-01104
    Total participants2011-03-01104
    2010
    Total participants, beginning-of-year2010-03-010
    Total number of active participants reported on line 7a of the Form 55002010-03-01101
    Number of retired or separated participants receiving benefits2010-03-010
    Number of other retired or separated participants entitled to future benefits2010-03-010
    Total of all active and inactive participants2010-03-01101
    Total participants2010-03-01101

    Form 5500 Responses

    2020
    2020-04-01Type of plan entitySingle employer plan
    2020-04-01Plan funding arrangement – InsuranceYes
    2020-04-01Plan benefit arrangement – InsuranceYes
    2019
    2019-03-01Type of plan entitySingle employer plan
    2019-03-01Plan funding arrangement – InsuranceYes
    2019-03-01Plan benefit arrangement – InsuranceYes
    2018
    2018-03-01Type of plan entitySingle employer plan
    2018-03-01Plan funding arrangement – InsuranceYes
    2018-03-01Plan benefit arrangement – InsuranceYes
    2017
    2017-03-01Type of plan entitySingle employer plan
    2017-03-01Plan funding arrangement – InsuranceYes
    2017-03-01Plan benefit arrangement – InsuranceYes
    2016
    2016-03-01Type of plan entitySingle employer plan
    2016-03-01Plan funding arrangement – InsuranceYes
    2016-03-01Plan benefit arrangement – InsuranceYes
    2015
    2015-03-01Type of plan entitySingle employer plan
    2015-03-01Plan funding arrangement – InsuranceYes
    2015-03-01Plan benefit arrangement – InsuranceYes
    2014
    2014-03-01Type of plan entitySingle employer plan
    2014-03-01Submission has been amendedNo
    2014-03-01This submission is the final filingNo
    2014-03-01This return/report is a short plan year return/report (less than 12 months)No
    2014-03-01Plan is a collectively bargained planNo
    2014-03-01Plan funding arrangement – InsuranceYes
    2014-03-01Plan benefit arrangement – InsuranceYes
    2013
    2013-03-01Type of plan entitySingle employer plan
    2013-03-01Submission has been amendedNo
    2013-03-01This submission is the final filingNo
    2013-03-01This return/report is a short plan year return/report (less than 12 months)No
    2013-03-01Plan is a collectively bargained planNo
    2013-03-01Plan funding arrangement – InsuranceYes
    2013-03-01Plan benefit arrangement – InsuranceYes
    2012
    2012-03-01Type of plan entitySingle employer plan
    2012-03-01Submission has been amendedNo
    2012-03-01This submission is the final filingNo
    2012-03-01This return/report is a short plan year return/report (less than 12 months)No
    2012-03-01Plan is a collectively bargained planNo
    2012-03-01Plan funding arrangement – InsuranceYes
    2012-03-01Plan benefit arrangement – InsuranceYes
    2011
    2011-03-01Type of plan entitySingle employer plan
    2011-03-01Submission has been amendedNo
    2011-03-01This submission is the final filingNo
    2011-03-01This return/report is a short plan year return/report (less than 12 months)No
    2011-03-01Plan is a collectively bargained planNo
    2011-03-01Plan funding arrangement – InsuranceYes
    2011-03-01Plan benefit arrangement – InsuranceYes
    2010
    2010-03-01Type of plan entitySingle employer plan
    2010-03-01First time form 5500 has been submittedYes
    2010-03-01Submission has been amendedNo
    2010-03-01This submission is the final filingNo
    2010-03-01This return/report is a short plan year return/report (less than 12 months)No
    2010-03-01Plan is a collectively bargained planNo
    2010-03-01Plan funding arrangement – InsuranceYes
    2010-03-01Plan benefit arrangement – InsuranceYes

    Insurance Providers Used on plan

    HUMANA HEALTH PLAN OF TEXAS, INC. (National Association of Insurance Commissioners NAIC id number: 95024 )
    Policy contract number837847
    Policy instance 5
    Insurance contract or identification number837847
    Number of Individuals Covered129
    Insurance policy start date2021-04-01
    Insurance policy end date2022-03-31
    Total amount of commissions paid to insurance brokerUSD $49,950
    Health Insurance Welfare BenefitYes
    Welfare Benefit Premiums Paid to CarrierUSD $908,733
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
    Commission paid to Insurance BrokerUSD $49,950
    Insurance broker organization code?3
    HUMANA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 73288 )
    Policy contract number837847
    Policy instance 4
    Insurance contract or identification number837847
    Number of Individuals Covered155
    Insurance policy start date2021-04-01
    Insurance policy end date2022-03-31
    Total amount of commissions paid to insurance brokerUSD $15,019
    Dental Insurance Welfare BenefitYes
    Vision Insurance Welfare BenefitYes
    Life Insurance Welfare BenefitYes
    Other welfare benefits providedHSA
    Welfare Benefit Premiums Paid to CarrierUSD $105,562
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
    Commission paid to Insurance BrokerUSD $15,019
    AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )
    Policy contract number82-2723296
    Policy instance 3
    Insurance contract or identification number82-2723296
    Number of Individuals Covered50
    Insurance policy start date2021-04-01
    Insurance policy end date2022-03-31
    Total amount of commissions paid to insurance brokerUSD $5,172
    Temporary Disability Insurance Welfare BenefitYes
    Long Term Disability Insurance Welfare BenefitYes
    Unemployment Insurance Welfare BenefitYes
    Welfare Benefit Premiums Paid to CarrierUSD $46,582
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
    Commission paid to Insurance BrokerUSD $2,333
    Additional information about fees paid to insurance brokerPROFITIBILITY BONUS
    Insurance broker organization code?3
    COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
    Policy contract numberE3355484
    Policy instance 2
    Insurance contract or identification numberE3355484
    Number of Individuals Covered3
    Insurance policy start date2021-04-01
    Insurance policy end date2022-03-31
    Total amount of commissions paid to insurance brokerUSD $284
    Health Insurance Welfare BenefitYes
    Temporary Disability Insurance Welfare BenefitYes
    Welfare Benefit Premiums Paid to CarrierUSD $3,265
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
    Commission paid to Insurance BrokerUSD $3
    Insurance broker organization code?3
    THE PAUL REVERE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 67598 )
    Policy contract number93792
    Policy instance 1
    Insurance contract or identification number93792
    Number of Individuals Covered39
    Insurance policy start date2021-04-01
    Insurance policy end date2022-03-31
    Total amount of commissions paid to insurance brokerUSD $2,448
    Total amount of fees paid to insurance companyUSD $128
    Long Term Disability Insurance Welfare BenefitYes
    Welfare Benefit Premiums Paid to CarrierUSD $17,082
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
    Commission paid to Insurance BrokerUSD $2,448
    Amount paid for insurance broker fees128
    Additional information about fees paid to insurance brokerPROFITIBILITY BONUS
    Insurance broker organization code?3
    THE PAUL REVERE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 67598 )
    Policy contract number93792
    Policy instance 1
    Insurance contract or identification number93792
    Number of Individuals Covered43
    Insurance policy start date2020-04-01
    Insurance policy end date2021-03-31
    Total amount of commissions paid to insurance brokerUSD $2,790
    Long Term Disability Insurance Welfare BenefitYes
    Welfare Benefit Premiums Paid to CarrierUSD $19,118
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
    Commission paid to Insurance BrokerUSD $2,647
    Insurance broker organization code?3
    COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
    Policy contract numberE3355484
    Policy instance 2
    Insurance contract or identification numberE3355484
    Number of Individuals Covered6
    Insurance policy start date2020-04-01
    Insurance policy end date2021-03-31
    Total amount of commissions paid to insurance brokerUSD $339
    Health Insurance Welfare BenefitYes
    Temporary Disability Insurance Welfare BenefitYes
    Welfare Benefit Premiums Paid to CarrierUSD $3,715
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
    Commission paid to Insurance BrokerUSD $110
    Insurance broker organization code?3
    AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )
    Policy contract number82-2723296
    Policy instance 3
    Insurance contract or identification number82-2723296
    Number of Individuals Covered57
    Insurance policy start date2020-04-01
    Insurance policy end date2021-03-31
    Total amount of commissions paid to insurance brokerUSD $6,169
    Total amount of fees paid to insurance companyUSD $229
    Temporary Disability Insurance Welfare BenefitYes
    Long Term Disability Insurance Welfare BenefitYes
    Unemployment Insurance Welfare BenefitYes
    Welfare Benefit Premiums Paid to CarrierUSD $55,368
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
    Commission paid to Insurance BrokerUSD $2,679
    Amount paid for insurance broker fees163
    Additional information about fees paid to insurance brokerPROFITIBILITY BONUS
    Insurance broker organization code?3
    HUMANA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 73288 )
    Policy contract number837847
    Policy instance 4
    Insurance contract or identification number837847
    Number of Individuals Covered153
    Insurance policy start date2020-04-01
    Insurance policy end date2021-03-31
    Total amount of commissions paid to insurance brokerUSD $17,204
    Dental Insurance Welfare BenefitYes
    Vision Insurance Welfare BenefitYes
    Life Insurance Welfare BenefitYes
    Other welfare benefits providedHSA
    Welfare Benefit Premiums Paid to CarrierUSD $104,275
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
    Commission paid to Insurance BrokerUSD $17,204
    Insurance broker organization code?3
    HUMANA HEALTH PLAN OF TEXAS, INC. (National Association of Insurance Commissioners NAIC id number: 95024 )
    Policy contract number837847
    Policy instance 5
    Insurance contract or identification number837847
    Number of Individuals Covered121
    Insurance policy start date2020-04-01
    Insurance policy end date2021-03-31
    Total amount of commissions paid to insurance brokerUSD $57,783
    Health Insurance Welfare BenefitYes
    Welfare Benefit Premiums Paid to CarrierUSD $942,354
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
    Commission paid to Insurance BrokerUSD $57,783
    Insurance broker organization code?3
    UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
    Policy contract number914130
    Policy instance 4
    Insurance contract or identification number914130
    Number of Individuals Covered362
    Insurance policy start date2019-03-01
    Insurance policy end date2020-02-29
    Total amount of commissions paid to insurance brokerUSD $8,313
    Total amount of fees paid to insurance companyUSD $53,582
    Health Insurance Welfare BenefitYes
    Dental Insurance Welfare BenefitYes
    Vision Insurance Welfare BenefitYes
    Life Insurance Welfare BenefitYes
    Welfare Benefit Premiums Paid to CarrierUSD $924,743
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
    Commission paid to Insurance BrokerUSD $8,310
    Amount paid for insurance broker fees53582
    Additional information about fees paid to insurance brokerSERVICE FEE AGREEMENT
    Insurance broker organization code?3
    AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )
    Policy contract number82-2723296
    Policy instance 3
    Insurance contract or identification number82-2723296
    Number of Individuals Covered70
    Insurance policy start date2019-03-01
    Insurance policy end date2020-02-29
    Total amount of commissions paid to insurance brokerUSD $9,655
    Total amount of fees paid to insurance companyUSD $419
    Temporary Disability Insurance Welfare BenefitYes
    Long Term Disability Insurance Welfare BenefitYes
    Unemployment Insurance Welfare BenefitYes
    Welfare Benefit Premiums Paid to CarrierUSD $67,639
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
    Commission paid to Insurance BrokerUSD $4,721
    Amount paid for insurance broker fees272
    Additional information about fees paid to insurance brokerPROFITIBILITY BONUS
    Insurance broker organization code?3
    COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
    Policy contract numberE3355484
    Policy instance 2
    Insurance contract or identification numberE3355484
    Number of Individuals Covered6
    Insurance policy start date2019-03-01
    Insurance policy end date2020-02-29
    Total amount of commissions paid to insurance brokerUSD $462
    Health Insurance Welfare BenefitYes
    Temporary Disability Insurance Welfare BenefitYes
    Welfare Benefit Premiums Paid to CarrierUSD $4,787
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
    Commission paid to Insurance BrokerUSD $166
    Insurance broker organization code?3
    THE PAUL REVERE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 67598 )
    Policy contract number93792
    Policy instance 1
    Insurance contract or identification number93792
    Number of Individuals Covered48
    Insurance policy start date2019-03-01
    Insurance policy end date2020-02-29
    Total amount of commissions paid to insurance brokerUSD $2,877
    Long Term Disability Insurance Welfare BenefitYes
    Welfare Benefit Premiums Paid to CarrierUSD $19,780
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
    Commission paid to Insurance BrokerUSD $2,729
    Insurance broker organization code?3
    HUMANA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 73288 )
    Policy contract number765316
    Policy instance 1
    Insurance contract or identification number765316
    Number of Individuals Covered147
    Insurance policy start date2017-03-01
    Insurance policy end date2018-02-28
    Total amount of commissions paid to insurance brokerUSD $9,589
    Dental Insurance Welfare BenefitYes
    Life Insurance Welfare BenefitYes
    Welfare Benefit Premiums Paid to CarrierUSD $95,379
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
    Commission paid to Insurance BrokerUSD $8,598
    Additional information about fees paid to insurance brokerN/A
    Insurance broker organization code?3
    Insurance broker nameKAREN K GREGORY
    HUMANA HEALTH PLAN OF TEXAS, INC. (National Association of Insurance Commissioners NAIC id number: 95024 )
    Policy contract number765316
    Policy instance 2
    Insurance contract or identification number765316
    Number of Individuals Covered113
    Insurance policy start date2017-03-01
    Insurance policy end date2018-02-28
    Total amount of commissions paid to insurance brokerUSD $43,997
    Health Insurance Welfare BenefitYes
    Welfare Benefit Premiums Paid to CarrierUSD $916,390
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
    Commission paid to Insurance BrokerUSD $45,137
    Additional information about fees paid to insurance brokerN/A
    Insurance broker organization code?3
    Insurance broker nameTHOMAS L. CARLISLE
    HUMANA (National Association of Insurance Commissioners NAIC id number: 70580 )
    Policy contract number765316
    Policy instance 3
    Insurance contract or identification number765316
    Number of Individuals Covered108
    Insurance policy start date2017-03-01
    Insurance policy end date2018-02-28
    Total amount of commissions paid to insurance brokerUSD $2,011
    Vision Insurance Welfare BenefitYes
    Welfare Benefit Premiums Paid to CarrierUSD $19,027
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
    Commission paid to Insurance BrokerUSD $1,836
    Additional information about fees paid to insurance brokerN/A
    Insurance broker organization code?3
    Insurance broker nameKAREN K GREGORY
    THE PAUL REVERE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 67598 )
    Policy contract number93792
    Policy instance 4
    Insurance contract or identification number93792
    Number of Individuals Covered48
    Insurance policy start date2017-03-01
    Insurance policy end date2018-02-28
    Total amount of commissions paid to insurance brokerUSD $2,929
    Health Insurance Welfare BenefitYes
    Welfare Benefit Premiums Paid to CarrierUSD $20,334
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
    Commission paid to Insurance BrokerUSD $2,929
    Additional information about fees paid to insurance brokerN/A
    Insurance broker organization code?3
    Insurance broker nameKAREN K GREGORY
    COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
    Policy contract numberE3355484
    Policy instance 5
    Insurance contract or identification numberE3355484
    Number of Individuals Covered8
    Insurance policy start date2017-03-01
    Insurance policy end date2018-02-28
    Total amount of commissions paid to insurance brokerUSD $699
    Life Insurance Welfare BenefitYes
    Welfare Benefit Premiums Paid to CarrierUSD $7,173
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
    Commission paid to Insurance BrokerUSD $248
    Additional information about fees paid to insurance brokerN/A
    Insurance broker organization code?3
    Insurance broker namePARAGON ADVISORY LLC
    AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )
    Policy contract number82-2723296
    Policy instance 6
    Insurance contract or identification number82-2723296
    Number of Individuals Covered58
    Insurance policy start date2017-03-01
    Insurance policy end date2018-02-28
    Total amount of commissions paid to insurance brokerUSD $11,434
    Total amount of fees paid to insurance companyUSD $489
    Temporary Disability Insurance Welfare BenefitYes
    Long Term Disability Insurance Welfare BenefitYes
    Unemployment Insurance Welfare BenefitYes
    Welfare Benefit Premiums Paid to CarrierUSD $64,109
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
    Commission paid to Insurance BrokerUSD $6,121
    Amount paid for insurance broker fees349
    Additional information about fees paid to insurance brokerPROFITIBILITY BONUS
    Insurance broker organization code?3
    Insurance broker nameMARK WOOD
    UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
    Policy contract number517299
    Policy instance 1
    Insurance contract or identification number517299
    Number of Individuals Covered170
    Insurance policy start date2013-03-01
    Insurance policy end date2014-02-28
    Total amount of commissions paid to insurance brokerUSD $34,612
    Are there contracts with allocated funds for individual policies?0
    Are there contracts with allocated funds for group deferred annuity?No
    Are there contracts with allocated funds for types other than group deferred annuity or individual?No
    Contract purchased, in whole or in part, to distribute benefits from a terminating 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 BenefitYes
    Dental Insurance Welfare BenefitYes
    Vision Insurance Welfare BenefitYes
    Life Insurance Welfare BenefitYes
    Temporary Disability Insurance Welfare BenefitYes
    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 $658,081
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
    Commission paid to Insurance BrokerUSD $34,612
    Insurance broker organization code?3
    Insurance broker nameKAREN K GREGORY
    UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
    Policy contract number517299
    Policy instance 1
    Insurance contract or identification number517299
    Number of Individuals Covered168
    Insurance policy start date2012-03-01
    Insurance policy end date2013-02-28
    Total amount of commissions paid to insurance brokerUSD $31,273
    Are there contracts with allocated funds for individual policies?0
    Are there contracts with allocated funds for group deferred annuity?No
    Are there contracts with allocated funds for types other than group deferred annuity or individual?No
    Contract purchased, in whole or in part, to distribute benefits from a terminating 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 BenefitYes
    Dental Insurance Welfare BenefitYes
    Vision Insurance Welfare BenefitYes
    Life Insurance Welfare BenefitYes
    Temporary Disability Insurance Welfare BenefitYes
    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 $595,681
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
    Commission paid to Insurance BrokerUSD $31,273
    Insurance broker organization code?3
    Insurance broker nameKAREN K GREGORY
    UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
    Policy contract number517299
    Policy instance 1
    Insurance contract or identification number517299
    Number of Individuals Covered104
    Insurance policy start date2011-03-01
    Insurance policy end date2012-02-29
    Total amount of commissions paid to insurance brokerUSD $31,927
    Are there contracts with allocated funds for individual policies?0
    Are there contracts with allocated funds for group deferred annuity?No
    Are there contracts with allocated funds for types other than group deferred annuity or individual?No
    Contract purchased, in whole or in part, to distribute benefits from a terminating 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 BenefitYes
    Dental Insurance Welfare BenefitYes
    Vision Insurance Welfare BenefitYes
    Life Insurance Welfare BenefitYes
    Temporary Disability Insurance Welfare BenefitYes
    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 $561,309
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
    Commission paid to Insurance BrokerUSD $31,927
    Insurance broker organization code?3
    Insurance broker nameKAREN K GREGORY
    UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
    Policy contract number517299
    Policy instance 1
    Insurance contract or identification number517299
    Number of Individuals Covered101
    Insurance policy start date2010-03-01
    Insurance policy end date2011-02-28
    Total amount of commissions paid to insurance brokerUSD $27,828
    Are there contracts with allocated funds for individual policies?0
    Are there contracts with allocated funds for group deferred annuity?No
    Are there contracts with allocated funds for types other than group deferred annuity or individual?No
    Contract purchased, in whole or in part, to distribute benefits from a terminating 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 BenefitYes
    Dental Insurance Welfare BenefitYes
    Vision Insurance Welfare BenefitYes
    Life Insurance Welfare BenefitYes
    Temporary Disability Insurance Welfare BenefitYes
    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 $535,509
    Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
    Commission paid to Insurance BrokerUSD $27,828
    Insurance broker organization code?3
    Insurance broker nameKAREN K GREGORY

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