LUCIX CORPORATION has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan LUCIX CORPORATION WELFARE BENEFIT PLAN
Measure | Date | Value |
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2022: LUCIX CORPORATION WELFARE BENEFIT PLAN 2022 401k membership |
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Total participants, beginning-of-year | 2022-05-01 | 151 |
Total number of active participants reported on line 7a of the Form 5500 | 2022-05-01 | 151 |
Number of retired or separated participants receiving benefits | 2022-05-01 | 0 |
Number of other retired or separated participants entitled to future benefits | 2022-05-01 | 0 |
Total of all active and inactive participants | 2022-05-01 | 151 |
Number of employers contributing to the scheme | 2022-05-01 | 0 |
2021: LUCIX CORPORATION WELFARE BENEFIT PLAN 2021 401k membership |
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Total participants, beginning-of-year | 2021-05-01 | 125 |
Total number of active participants reported on line 7a of the Form 5500 | 2021-05-01 | 140 |
Number of retired or separated participants receiving benefits | 2021-05-01 | 0 |
Number of other retired or separated participants entitled to future benefits | 2021-05-01 | 0 |
Total of all active and inactive participants | 2021-05-01 | 140 |
Number of employers contributing to the scheme | 2021-05-01 | 0 |
2020: LUCIX CORPORATION WELFARE BENEFIT PLAN 2020 401k membership |
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Total participants, beginning-of-year | 2020-05-01 | 123 |
Total number of active participants reported on line 7a of the Form 5500 | 2020-05-01 | 125 |
Number of retired or separated participants receiving benefits | 2020-05-01 | 0 |
Number of other retired or separated participants entitled to future benefits | 2020-05-01 | 0 |
Total of all active and inactive participants | 2020-05-01 | 125 |
Number of employers contributing to the scheme | 2020-05-01 | 0 |
2019: LUCIX CORPORATION WELFARE BENEFIT PLAN 2019 401k membership |
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Total participants, beginning-of-year | 2019-05-01 | 120 |
Total number of active participants reported on line 7a of the Form 5500 | 2019-05-01 | 121 |
Number of retired or separated participants receiving benefits | 2019-05-01 | 0 |
Number of other retired or separated participants entitled to future benefits | 2019-05-01 | 0 |
Total of all active and inactive participants | 2019-05-01 | 121 |
Number of employers contributing to the scheme | 2019-05-01 | 0 |
2018: LUCIX CORPORATION WELFARE BENEFIT PLAN 2018 401k membership |
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Total participants, beginning-of-year | 2018-05-01 | 140 |
Total number of active participants reported on line 7a of the Form 5500 | 2018-05-01 | 120 |
Number of retired or separated participants receiving benefits | 2018-05-01 | 0 |
Number of other retired or separated participants entitled to future benefits | 2018-05-01 | 0 |
Total of all active and inactive participants | 2018-05-01 | 120 |
2017: LUCIX CORPORATION WELFARE BENEFIT PLAN 2017 401k membership |
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Total participants, beginning-of-year | 2017-05-01 | 144 |
Total number of active participants reported on line 7a of the Form 5500 | 2017-05-01 | 140 |
Number of retired or separated participants receiving benefits | 2017-05-01 | 0 |
Number of other retired or separated participants entitled to future benefits | 2017-05-01 | 0 |
Total of all active and inactive participants | 2017-05-01 | 140 |
2016: LUCIX CORPORATION WELFARE BENEFIT PLAN 2016 401k membership |
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Total participants, beginning-of-year | 2016-05-01 | 142 |
Total number of active participants reported on line 7a of the Form 5500 | 2016-05-01 | 140 |
Number of retired or separated participants receiving benefits | 2016-05-01 | 0 |
Number of other retired or separated participants entitled to future benefits | 2016-05-01 | 0 |
Total of all active and inactive participants | 2016-05-01 | 140 |
2015: LUCIX CORPORATION WELFARE BENEFIT PLAN 2015 401k membership |
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Total participants, beginning-of-year | 2015-08-01 | 141 |
Total number of active participants reported on line 7a of the Form 5500 | 2015-08-01 | 148 |
Number of retired or separated participants receiving benefits | 2015-08-01 | 0 |
Number of other retired or separated participants entitled to future benefits | 2015-08-01 | 0 |
Total of all active and inactive participants | 2015-08-01 | 148 |
2014: LUCIX CORPORATION WELFARE BENEFIT PLAN 2014 401k membership |
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Total participants, beginning-of-year | 2014-08-01 | 131 |
Total number of active participants reported on line 7a of the Form 5500 | 2014-08-01 | 134 |
Number of retired or separated participants receiving benefits | 2014-08-01 | 1 |
Number of other retired or separated participants entitled to future benefits | 2014-08-01 | 0 |
Total of all active and inactive participants | 2014-08-01 | 135 |
2013: LUCIX CORPORATION WELFARE BENEFIT PLAN 2013 401k membership |
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Total participants, beginning-of-year | 2013-08-01 | 138 |
Total number of active participants reported on line 7a of the Form 5500 | 2013-08-01 | 143 |
Number of retired or separated participants receiving benefits | 2013-08-01 | 1 |
Number of other retired or separated participants entitled to future benefits | 2013-08-01 | 0 |
Total of all active and inactive participants | 2013-08-01 | 144 |
2012: LUCIX CORPORATION WELFARE BENEFIT PLAN 2012 401k membership |
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Total participants, beginning-of-year | 2012-08-01 | 115 |
Total number of active participants reported on line 7a of the Form 5500 | 2012-08-01 | 134 |
Number of retired or separated participants receiving benefits | 2012-08-01 | 0 |
Number of other retired or separated participants entitled to future benefits | 2012-08-01 | 0 |
Total of all active and inactive participants | 2012-08-01 | 134 |
2011: LUCIX CORPORATION WELFARE BENEFIT PLAN 2011 401k membership |
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Total participants, beginning-of-year | 2011-08-01 | 125 |
Total number of active participants reported on line 7a of the Form 5500 | 2011-08-01 | 114 |
Number of retired or separated participants receiving benefits | 2011-08-01 | 1 |
Number of other retired or separated participants entitled to future benefits | 2011-08-01 | 0 |
Total of all active and inactive participants | 2011-08-01 | 115 |
2022: LUCIX CORPORATION WELFARE BENEFIT PLAN 2022 form 5500 responses |
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2022-05-01 | Type of plan entity | Single employer plan |
2022-05-01 | Plan funding arrangement – Insurance | Yes |
2022-05-01 | Plan benefit arrangement – Insurance | Yes |
2021: LUCIX CORPORATION WELFARE BENEFIT PLAN 2021 form 5500 responses |
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2021-05-01 | Type of plan entity | Single employer plan |
2021-05-01 | Plan funding arrangement – Insurance | Yes |
2021-05-01 | Plan benefit arrangement – Insurance | Yes |
2020: LUCIX CORPORATION WELFARE BENEFIT PLAN 2020 form 5500 responses |
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2020-05-01 | Type of plan entity | Single employer plan |
2020-05-01 | Plan funding arrangement – Insurance | Yes |
2020-05-01 | Plan benefit arrangement – Insurance | Yes |
2019: LUCIX CORPORATION WELFARE BENEFIT PLAN 2019 form 5500 responses |
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2019-05-01 | Type of plan entity | Single employer plan |
2019-05-01 | Plan funding arrangement – Insurance | Yes |
2019-05-01 | Plan benefit arrangement – Insurance | Yes |
2018: LUCIX CORPORATION WELFARE BENEFIT PLAN 2018 form 5500 responses |
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2018-05-01 | Type of plan entity | Single employer plan |
2018-05-01 | Submission has been amended | No |
2018-05-01 | This submission is the final filing | No |
2018-05-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2018-05-01 | Plan is a collectively bargained plan | No |
2018-05-01 | Plan funding arrangement – Insurance | Yes |
2018-05-01 | Plan benefit arrangement – Insurance | Yes |
2017: LUCIX CORPORATION WELFARE BENEFIT PLAN 2017 form 5500 responses |
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2017-05-01 | Type of plan entity | Single employer plan |
2017-05-01 | Submission has been amended | No |
2017-05-01 | This submission is the final filing | No |
2017-05-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2017-05-01 | Plan is a collectively bargained plan | No |
2017-05-01 | Plan funding arrangement – Insurance | Yes |
2017-05-01 | Plan benefit arrangement – Insurance | Yes |
2016: LUCIX CORPORATION WELFARE BENEFIT PLAN 2016 form 5500 responses |
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2016-05-01 | Type of plan entity | Single employer plan |
2016-05-01 | Submission has been amended | No |
2016-05-01 | This submission is the final filing | No |
2016-05-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2016-05-01 | Plan is a collectively bargained plan | No |
2016-05-01 | Plan funding arrangement – Insurance | Yes |
2016-05-01 | Plan benefit arrangement – Insurance | Yes |
2015: LUCIX CORPORATION WELFARE BENEFIT PLAN 2015 form 5500 responses |
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2015-08-01 | Type of plan entity | Single employer plan |
2015-08-01 | Submission has been amended | No |
2015-08-01 | This submission is the final filing | No |
2015-08-01 | This return/report is a short plan year return/report (less than 12 months) | Yes |
2015-08-01 | Plan is a collectively bargained plan | No |
2015-08-01 | Plan funding arrangement – Insurance | Yes |
2015-08-01 | Plan benefit arrangement – Insurance | Yes |
2014: LUCIX CORPORATION WELFARE BENEFIT PLAN 2014 form 5500 responses |
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2014-08-01 | Type of plan entity | Single employer plan |
2014-08-01 | Submission has been amended | No |
2014-08-01 | This submission is the final filing | No |
2014-08-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2014-08-01 | Plan is a collectively bargained plan | No |
2014-08-01 | Plan funding arrangement – Insurance | Yes |
2014-08-01 | Plan benefit arrangement – Insurance | Yes |
2013: LUCIX CORPORATION WELFARE BENEFIT PLAN 2013 form 5500 responses |
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2013-08-01 | Type of plan entity | Single employer plan |
2013-08-01 | Submission has been amended | No |
2013-08-01 | This submission is the final filing | No |
2013-08-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2013-08-01 | Plan is a collectively bargained plan | No |
2013-08-01 | Plan funding arrangement – Insurance | Yes |
2013-08-01 | Plan benefit arrangement – Insurance | Yes |
2012: LUCIX CORPORATION WELFARE BENEFIT PLAN 2012 form 5500 responses |
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2012-08-01 | Type of plan entity | Single employer plan |
2012-08-01 | Submission has been amended | No |
2012-08-01 | This submission is the final filing | No |
2012-08-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2012-08-01 | Plan is a collectively bargained plan | No |
2012-08-01 | Plan funding arrangement – Insurance | Yes |
2012-08-01 | Plan benefit arrangement – Insurance | Yes |
2011: LUCIX CORPORATION WELFARE BENEFIT PLAN 2011 form 5500 responses |
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2011-08-01 | Type of plan entity | Single employer plan |
2011-08-01 | First time form 5500 has been submitted | Yes |
2011-08-01 | Submission has been amended | No |
2011-08-01 | This submission is the final filing | No |
2011-08-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2011-08-01 | Plan is a collectively bargained plan | No |
2011-08-01 | Plan funding arrangement – Insurance | Yes |
2011-08-01 | Plan benefit arrangement – Insurance | Yes |
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
Policy contract number | GLUG0BQCQ |
Policy instance | 4 |
Insurance contract or identification number | GLUG0BQCQ | Number of Individuals Covered | 134 | Insurance policy start date | 2022-05-01 | Insurance policy end date | 2023-04-30 | Total amount of commissions paid to insurance broker | USD $8,654 | Total amount of fees paid to insurance company | USD $7,760 | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | Yes | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | Welfare Benefit Premiums Paid to Carrier | USD $86,530 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $8,654 | Amount paid for insurance broker fees | 5173 | Additional information about fees paid to insurance broker | OTHER COMPENSATION | Insurance broker organization code? | 3 |
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AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
Policy contract number | 149074 |
Policy instance | 3 |
Insurance contract or identification number | 149074 | Number of Individuals Covered | 324 | Insurance policy start date | 2022-05-01 | Insurance policy end date | 2023-04-30 | Total amount of commissions paid to insurance broker | USD $28,177 | Total amount of fees paid to insurance company | USD $3,150 | Health Insurance Welfare Benefit | Yes | Dental Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $344,157 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $26,233 | Amount paid for insurance broker fees | 3150 | Additional information about fees paid to insurance broker | 2022 SIGNATURE MEDICAL RETENTION INCENTIVE RISK | Insurance broker organization code? | 3 |
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AETNA HEALTH, INC. (National Association of Insurance Commissioners NAIC id number: 00000 ) |
Policy contract number | 149074HNO |
Policy instance | 2 |
Insurance contract or identification number | 149074HNO | Number of Individuals Covered | 177 | Insurance policy start date | 2022-05-01 | Insurance policy end date | 2023-04-30 | Total amount of commissions paid to insurance broker | USD $81,717 | Total amount of fees paid to insurance company | USD $0 | Health Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $1,355,534 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $67,825 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
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PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 ) |
Policy contract number | 1126999 |
Policy instance | 1 |
Insurance contract or identification number | 1126999 | Number of Individuals Covered | 327 | Insurance policy start date | 2022-05-01 | Insurance policy end date | 2023-04-30 | Total amount of commissions paid to insurance broker | USD $2,429 | Total amount of fees paid to insurance company | USD $0 | Vision Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $23,735 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $1,719 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
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PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 ) |
Policy contract number | 1126999 |
Policy instance | 1 |
Insurance contract or identification number | 1126999 | Number of Individuals Covered | 344 | Insurance policy start date | 2021-05-01 | Insurance policy end date | 2022-04-30 | Total amount of commissions paid to insurance broker | USD $2,290 | Total amount of fees paid to insurance company | USD $0 | Vision Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $22,085 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $1,627 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
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AETNA HEALTH, INC. (National Association of Insurance Commissioners NAIC id number: 00000 ) |
Policy contract number | 149074HNO |
Policy instance | 2 |
Insurance contract or identification number | 149074HNO | Number of Individuals Covered | 224 | Insurance policy start date | 2021-05-01 | Insurance policy end date | 2022-04-30 | Total amount of commissions paid to insurance broker | USD $87,251 | Total amount of fees paid to insurance company | USD $0 | Health Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $1,443,909 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $72,418 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
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KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
Policy contract number | 228412 |
Policy instance | 3 |
Insurance contract or identification number | 228412 | Number of Individuals Covered | 289 | Insurance policy start date | 2021-05-01 | Insurance policy end date | 2022-04-30 | Total amount of commissions paid to insurance broker | USD $33,469 | Total amount of fees paid to insurance company | USD $0 | Health Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $2,082,314 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $33,469 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
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AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
Policy contract number | 149074 |
Policy instance | 4 |
Insurance contract or identification number | 149074 | Number of Individuals Covered | 352 | Insurance policy start date | 2021-05-01 | Insurance policy end date | 2022-04-30 | Total amount of commissions paid to insurance broker | USD $27,208 | Total amount of fees paid to insurance company | USD $3,390 | Health Insurance Welfare Benefit | Yes | Dental Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $356,403 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $25,201 | Amount paid for insurance broker fees | 3390 | Additional information about fees paid to insurance broker | 2021 SIGNATURE MEDICAL RETENTION INCENTIVE RISK | Insurance broker organization code? | 3 |
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MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
Policy contract number | GLUG0BQCQ |
Policy instance | 5 |
Insurance contract or identification number | GLUG0BQCQ | Number of Individuals Covered | 145 | Insurance policy start date | 2021-05-01 | Insurance policy end date | 2022-04-30 | Total amount of commissions paid to insurance broker | USD $7,872 | Total amount of fees paid to insurance company | USD $5,686 | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | Yes | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | Welfare Benefit Premiums Paid to Carrier | USD $78,714 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $7,872 | Amount paid for insurance broker fees | 3412 | Additional information about fees paid to insurance broker | OTHER COMPENSATION | Insurance broker organization code? | 3 |
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PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 ) |
Policy contract number | 1126999 |
Policy instance | 1 |
Insurance contract or identification number | 1126999 | Number of Individuals Covered | 352 | Insurance policy start date | 2020-05-01 | Insurance policy end date | 2021-04-30 | Total amount of commissions paid to insurance broker | USD $2,219 | Total amount of fees paid to insurance company | USD $816 | Vision Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $21,356 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $1,579 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 | Additional information about fees paid to insurance broker | BONUS |
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AETNA HEALTH, INC. (National Association of Insurance Commissioners NAIC id number: 00000 ) |
Policy contract number | 149074HNO |
Policy instance | 2 |
Insurance contract or identification number | 149074HNO | Number of Individuals Covered | 232 | Insurance policy start date | 2020-05-01 | Insurance policy end date | 2021-04-30 | Total amount of commissions paid to insurance broker | USD $84,579 | Total amount of fees paid to insurance company | USD $0 | Health Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $1,446,846 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $71,051 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
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KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
Policy contract number | 228412 |
Policy instance | 3 |
Insurance contract or identification number | 228412 | Number of Individuals Covered | 306 | Insurance policy start date | 2020-05-01 | Insurance policy end date | 2021-04-30 | Total amount of commissions paid to insurance broker | USD $37,524 | Total amount of fees paid to insurance company | USD $0 | Health Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $2,144,320 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $37,524 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
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AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
Policy contract number | 149074 |
Policy instance | 4 |
Insurance contract or identification number | 149074 | Number of Individuals Covered | 344 | Insurance policy start date | 2020-05-01 | Insurance policy end date | 2021-04-30 | Total amount of commissions paid to insurance broker | USD $23,222 | Total amount of fees paid to insurance company | USD $4,227 | Health Insurance Welfare Benefit | Yes | Dental Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $282,907 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $21,928 | Amount paid for insurance broker fees | 4227 | Additional information about fees paid to insurance broker | 2020 Q4 SIGNATURE SPECIALTY NEW BUSINESS INCENTIVE RISK | Insurance broker organization code? | 3 |
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MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
Policy contract number | GLUG0BQCQ |
Policy instance | 5 |
Insurance contract or identification number | GLUG0BQCQ | Number of Individuals Covered | 133 | Insurance policy start date | 2020-05-01 | Insurance policy end date | 2021-04-30 | Total amount of commissions paid to insurance broker | USD $7,092 | Total amount of fees paid to insurance company | USD $1,705 | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | Yes | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | Welfare Benefit Premiums Paid to Carrier | USD $70,915 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $7,092 | Amount paid for insurance broker fees | 1705 | Additional information about fees paid to insurance broker | OTHER COMPENSATION | Insurance broker organization code? | 3 |
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UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 ) |
Policy contract number | 921496-000/099 |
Policy instance | 3 |
Insurance contract or identification number | 921496-000/099 | Number of Individuals Covered | 309 | Insurance policy start date | 2019-05-01 | Insurance policy end date | 2020-04-30 | Total amount of commissions paid to insurance broker | USD $12,486 | Total amount of fees paid to insurance company | USD $0 | Dental Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $135,627 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | Commission paid to Insurance Broker | USD $12,486 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
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UNITED CONCORDIA DENTAL PLANS OF CALIFORNIA, INC. (National Association of Insurance Commissioners NAIC id number: 95789 ) |
Policy contract number | 921496-001/199 |
Policy instance | 2 |
Insurance contract or identification number | 921496-001/199 | Number of Individuals Covered | 6 | Insurance policy start date | 2019-05-01 | Insurance policy end date | 2020-04-30 | Total amount of commissions paid to insurance broker | USD $63 | Total amount of fees paid to insurance company | USD $0 | Dental Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $679 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | Commission paid to Insurance Broker | USD $63 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
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BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
Policy contract number | 153688 |
Policy instance | 1 |
Insurance contract or identification number | 153688 | Number of Individuals Covered | 305 | Insurance policy start date | 2019-05-01 | Insurance policy end date | 2020-04-30 | Total amount of commissions paid to insurance broker | USD $56,444 | Total amount of fees paid to insurance company | USD $36,300 | Health Insurance Welfare Benefit | Yes | Vision Insurance Welfare Benefit | Yes | Life Insurance Welfare Benefit | Yes | Long Term Disability Insurance Welfare Benefit | Yes | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | Welfare Benefit Premiums Paid to Carrier | USD $2,050,038 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $56,444 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 | Additional information about fees paid to insurance broker | FEES |
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ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 ) |
Policy contract number | 153688 |
Policy instance | 1 |
Insurance contract or identification number | 153688 | Number of Individuals Covered | 319 | Insurance policy start date | 2018-05-01 | Insurance policy end date | 2019-04-30 | Total amount of commissions paid to insurance broker | USD $53,137 | Total amount of fees paid to insurance company | USD $33,569 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | Yes | Dental Insurance Welfare Benefit | Yes | Vision Insurance Welfare Benefit | Yes | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | Yes | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $1,912,467 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $36,716 | Insurance broker organization code? | 3 | Amount paid for insurance broker fees | 23614 | Additional information about fees paid to insurance broker | BONUS, OVERRIDE, AND NON-MONETARY COMPENSATION |
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UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 ) |
Policy contract number | 921496-000/099 |
Policy instance | 2 |
Insurance contract or identification number | 921496-000/099 | Number of Individuals Covered | 343 | Insurance policy start date | 2018-05-01 | Insurance policy end date | 2019-04-30 | Total amount of commissions paid to insurance broker | USD $13,992 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | Yes | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $140,205 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $13,992 | Insurance broker organization code? | 3 |
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UNITED CONCORDIA DENTAL PLANS OF CALIFORNIA, INC. (National Association of Insurance Commissioners NAIC id number: 95789 ) |
Policy contract number | 921496-199/001 |
Policy instance | 3 |
Insurance contract or identification number | 921496-199/001 | Number of Individuals Covered | 9 | Insurance policy start date | 2018-05-01 | Insurance policy end date | 2019-04-30 | Total amount of commissions paid to insurance broker | USD $120 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | Yes | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $1,204 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $120 | Insurance broker organization code? | 3 |
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BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
Policy contract number | 153688 |
Policy instance | 1 |
Insurance contract or identification number | 153688 | Number of Individuals Covered | 144 | Insurance policy start date | 2017-05-01 | Insurance policy end date | 2018-04-30 | Total amount of commissions paid to insurance broker | USD $69,010 | Total amount of fees paid to insurance company | USD $38,644 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | Yes | Dental Insurance Welfare Benefit | Yes | Vision Insurance Welfare Benefit | Yes | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | Yes | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $2,201,236 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $69,010 | Insurance broker organization code? | 3 | Amount paid for insurance broker fees | 38644 | Additional information about fees paid to insurance broker | BONUS, OVERRIDE AND NON-MONETARY COMPENSATION | Insurance broker name | LISI, INC. |
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BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
Policy contract number | 153688 |
Policy instance | 1 |
Insurance contract or identification number | 153688 | Number of Individuals Covered | 147 | Insurance policy start date | 2015-08-01 | Insurance policy end date | 2016-04-30 | Total amount of commissions paid to insurance broker | USD $58,535 | Total amount of fees paid to insurance company | USD $28,326 | Are there contracts with allocated funds for individual policies? | No | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | Yes | Dental Insurance Welfare Benefit | Yes | Vision Insurance Welfare Benefit | Yes | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | Yes | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $1,620,955 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $58,535 | Insurance broker organization code? | 3 | Amount paid for insurance broker fees | 28326 | Additional information about fees paid to insurance broker | BONUS, OVERRIDE AND NON-MONETARY COMPENSATION | Insurance broker name | LISI, INC. |
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BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
Policy contract number | 153688 |
Policy instance | 1 |
Insurance contract or identification number | 153688 | Number of Individuals Covered | 142 | Insurance policy start date | 2014-08-01 | Insurance policy end date | 2015-07-31 | Total amount of commissions paid to insurance broker | USD $98,864 | Total amount of fees paid to insurance company | USD $36,936 | Are there contracts with allocated funds for individual policies? | No | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | Yes | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | Yes | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $1,891,350 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $98,864 | Insurance broker organization code? | 3 | Amount paid for insurance broker fees | 36936 | Additional information about fees paid to insurance broker | BONUS, OVERRIDE AND NON-MONETARY COMPENSATION | Insurance broker name | LISI, INC. |
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VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 ) |
Policy contract number | 12241089 |
Policy instance | 2 |
Insurance contract or identification number | 12241089 | Number of Individuals Covered | 141 | Insurance policy start date | 2014-08-01 | Insurance policy end date | 2015-07-31 | Total amount of commissions paid to insurance broker | USD $1,124 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | No | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | Yes | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $20,606 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $1,124 | Insurance broker organization code? | 3 | Insurance broker name | CLEVIDENCE INSURANCE SERVICES, INC. |
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METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
Policy contract number | TS05919107 |
Policy instance | 3 |
Insurance contract or identification number | TS05919107 | Number of Individuals Covered | 575 | Insurance policy start date | 2014-08-01 | Insurance policy end date | 2015-07-31 | Total amount of commissions paid to insurance broker | USD $12,475 | Total amount of fees paid to insurance company | USD $3,988 | Are there contracts with allocated funds for individual policies? | No | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | Yes | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $192,312 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $8,000 | Amount paid for insurance broker fees | 798 | Additional information about fees paid to insurance broker | SUPPLEMENTAL COMPENSATION | Insurance broker organization code? | 3 | Insurance broker name | CLEVIDENCE INSURANCE SERVICES INC. |
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SAFEGUARD HEALTH PLANS, INC. A CALIFORNIA CORPORATION (National Association of Insurance Commissioners NAIC id number: 96030 ) |
Policy contract number | TS05919107 |
Policy instance | 4 |
Insurance contract or identification number | TS05919107 | Number of Individuals Covered | 40 | Insurance policy start date | 2014-08-01 | Insurance policy end date | 2015-07-31 | Total amount of commissions paid to insurance broker | USD $432 | Total amount of fees paid to insurance company | USD $130 | Are there contracts with allocated funds for individual policies? | No | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | Yes | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $3,458 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $288 | Amount paid for insurance broker fees | 58 | Additional information about fees paid to insurance broker | SUPPLEMENTAL COMPENSATION | Insurance broker organization code? | 3 | Insurance broker name | LISI INSURANCE SERVICES INC. |
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BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
Policy contract number | 153688 |
Policy instance | 1 |
Insurance contract or identification number | 153688 | Number of Individuals Covered | 151 | Insurance policy start date | 2013-08-01 | Insurance policy end date | 2014-07-31 | Total amount of commissions paid to insurance broker | USD $102,993 | Total amount of fees paid to insurance company | USD $42,883 | Are there contracts with allocated funds for individual policies? | No | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | Yes | Dental Insurance Welfare Benefit | Yes | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | Yes | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $2,070,458 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $102,993 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 | Additional information about fees paid to insurance broker | BONUS, OVERRIDE AND NON-MONETARY COMPENSATION | Insurance broker name | LISI, INC. |
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VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 ) |
Policy contract number | 12241089 |
Policy instance | 2 |
Insurance contract or identification number | 12241089 | Number of Individuals Covered | 139 | Insurance policy start date | 2013-08-01 | Insurance policy end date | 2014-07-31 | Total amount of commissions paid to insurance broker | USD $1,141 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | No | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | Yes | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $21,109 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $1,141 | Insurance broker organization code? | 3 | Insurance broker name | CLEVIDENCE INSURANCE SERVICES, INC. |
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VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 ) |
Policy contract number | 12241089 |
Policy instance | 2 |
Insurance contract or identification number | 12241089 | Number of Individuals Covered | 131 | Insurance policy start date | 2012-08-01 | Insurance policy end date | 2013-07-31 | Total amount of commissions paid to insurance broker | USD $1,054 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | No | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | Yes | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $18,817 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $1,054 | Insurance broker organization code? | 3 | Insurance broker name | CLEVIDENCE INSURANCE SERVICES, INC. |
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MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
Policy contract number | GLUG0AJKY |
Policy instance | 3 |
Insurance contract or identification number | GLUG0AJKY | Number of Individuals Covered | 132 | Insurance policy start date | 2012-08-01 | Insurance policy end date | 2013-07-31 | Total amount of commissions paid to insurance broker | USD $1,472 | Total amount of fees paid to insurance company | USD $861 | Are there contracts with allocated funds for individual policies? | No | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $14,719 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $1,472 | Amount paid for insurance broker fees | 861 | Additional information about fees paid to insurance broker | OTHER COMPENSATION | Insurance broker organization code? | 3 | Insurance broker name | CLEVIDENCE INSURANCE SERVICES, INC. |
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MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
Policy contract number | GLTD0AJKY |
Policy instance | 4 |
Insurance contract or identification number | GLTD0AJKY | Number of Individuals Covered | 132 | Insurance policy start date | 2012-08-01 | Insurance policy end date | 2013-07-31 | Total amount of commissions paid to insurance broker | USD $4,056 | Total amount of fees paid to insurance company | USD $866 | Are there contracts with allocated funds for individual policies? | No | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | Yes | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $20,279 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $4,056 | Amount paid for insurance broker fees | 866 | Additional information about fees paid to insurance broker | OTHER COMPENSATION | Insurance broker organization code? | 3 | Insurance broker name | CLEVIDENCE INSURANCE SERVICES, INC. |
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MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
Policy contract number | GVTL0AJKY |
Policy instance | 5 |
Insurance contract or identification number | GVTL0AJKY | Number of Individuals Covered | 57 | Insurance policy start date | 2012-08-01 | Insurance policy end date | 2013-07-31 | Total amount of commissions paid to insurance broker | USD $3,674 | Total amount of fees paid to insurance company | USD $976 | Are there contracts with allocated funds for individual policies? | No | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $24,493 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $2,462 | Amount paid for insurance broker fees | 799 | Additional information about fees paid to insurance broker | OTHER COMPENSATION | Insurance broker organization code? | 3 | Insurance broker name | THOMAS EDWARD BRADBURY |
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BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
Policy contract number | 153688 |
Policy instance | 1 |
Insurance contract or identification number | 153688 | Number of Individuals Covered | 133 | Insurance policy start date | 2012-08-01 | Insurance policy end date | 2013-07-31 | Total amount of commissions paid to insurance broker | USD $83,407 | Total amount of fees paid to insurance company | USD $33,314 | Are there contracts with allocated funds for individual policies? | No | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | Yes | Dental Insurance Welfare Benefit | Yes | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $1,688,704 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $83,407 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 | Additional information about fees paid to insurance broker | BONUS, OVERRIDE AND NON-MONETARY COMPENSATION | Insurance broker name | LISI, INC. |
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MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
Policy contract number | GVTL0AJKY |
Policy instance | 5 |
Insurance contract or identification number | GVTL0AJKY | Number of Individuals Covered | 56 | Insurance policy start date | 2011-08-01 | Insurance policy end date | 2012-07-31 | Total amount of commissions paid to insurance broker | USD $3,983 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | No | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $25,265 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
Policy contract number | GLTD0AJKY |
Policy instance | 4 |
Insurance contract or identification number | GLTD0AJKY | Number of Individuals Covered | 113 | Insurance policy start date | 2011-08-01 | Insurance policy end date | 2012-07-31 | Total amount of commissions paid to insurance broker | USD $3,224 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | No | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | Yes | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $15,330 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
Policy contract number | GLUG0AJKY |
Policy instance | 3 |
Insurance contract or identification number | GLUG0AJKY | Number of Individuals Covered | 113 | Insurance policy start date | 2011-08-01 | Insurance policy end date | 2012-07-31 | Total amount of commissions paid to insurance broker | USD $2,261 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | No | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $18,903 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 ) |
Policy contract number | 12241089 |
Policy instance | 2 |
Insurance contract or identification number | 12241089 | Number of Individuals Covered | 119 | Insurance policy start date | 2011-08-01 | Insurance policy end date | 2012-07-31 | Total amount of commissions paid to insurance broker | USD $1,175 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | No | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | Yes | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $21,921 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
Policy contract number | 153688 |
Policy instance | 1 |
Insurance contract or identification number | 153688 | Number of Individuals Covered | 110 | Insurance policy start date | 2011-08-01 | Insurance policy end date | 2012-07-31 | Total amount of commissions paid to insurance broker | USD $64,166 | Total amount of fees paid to insurance company | USD $24,523 | Are there contracts with allocated funds for individual policies? | No | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | Yes | Dental Insurance Welfare Benefit | Yes | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $1,350,431 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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