EP BLAZER, LLC has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan EP BLAZER, LLC DBA JOHN ELWAY CHEVROLET ON BROADWAY
401k plan membership statisitcs for EP BLAZER, LLC DBA JOHN ELWAY CHEVROLET ON BROADWAY
| KAISER FOUNDATION HEALTH PLAN OF COLORADO (National Association of Insurance Commissioners NAIC id number: 95669 ) |
| Policy contract number | 47213 |
| Policy instance | 2 |
| Insurance contract or identification number | 47213 | | Number of Individuals Covered | 67 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $18,598 | | Total amount of fees paid to insurance company | USD $6,875 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $410,255 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $18,598 | | Amount paid for insurance broker fees | 6875 | | Additional information about fees paid to insurance broker | BONUS | | Insurance broker organization code? | 3 |
|
| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
| Policy contract number | KM05956091 |
| Policy instance | 1 |
| Insurance contract or identification number | KM05956091 | | Number of Individuals Covered | 518 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $15,734 | | Total amount of fees paid to insurance company | USD $1,162 | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $143,815 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $15,734 | | Amount paid for insurance broker fees | 1162 | | Additional information about fees paid to insurance broker | NON-MONETARY COMPENSATION, SUPPLEMENTAL COMPENSATION | | Insurance broker organization code? | 3 |
|
| AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 ) |
| Policy contract number | 66236 |
| Policy instance | 3 |
| Insurance contract or identification number | 66236 | | Number of Individuals Covered | 181 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $8,635 | | Total amount of fees paid to insurance company | USD $1,629 | | 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, EMPLOYEE ASSISTANCE PROGRAM, ACCIDENT, CRITICAL ILLNESS,ACCIDENT | | Welfare Benefit Premiums Paid to Carrier | USD $195,883 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,628 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Additional information about fees paid to insurance broker | FEES |
|
| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
| Policy contract number | 5956091 |
| Policy instance | 3 |
| Insurance contract or identification number | 5956091 | | Number of Individuals Covered | 473 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $14,270 | | Total amount of fees paid to insurance company | USD $1,905 | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $128,135 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $14,270 | | Amount paid for insurance broker fees | 1905 | | Additional information about fees paid to insurance broker | NON-MONETARY COMPENSATION, SUPPLEMENTAL COMPENSATION | | Insurance broker organization code? | 3 |
|
| AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 ) |
| Policy contract number | 66236 |
| Policy instance | 2 |
| Insurance contract or identification number | 66236 | | Number of Individuals Covered | 73 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $4,342 | | Total amount of fees paid to insurance company | USD $902 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $87,947 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $4,257 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Additional information about fees paid to insurance broker | FEES |
|
| ROCKY MOUNTAIN HOSPITAL AND MEDICAL SERVICE, INC. (National Association of Insurance Commissioners NAIC id number: 11011 ) |
| Policy contract number | L01258 |
| Policy instance | 1 |
| Insurance contract or identification number | L01258 | | Number of Individuals Covered | 237 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $49,807 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,156,086 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $49,807 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| BANNER HEALTH AND AETNA HEALTH (National Association of Insurance Commissioners NAIC id number: 16058 ) |
| Policy contract number | 0108903BH |
| Policy instance | 1 |
| Insurance contract or identification number | 0108903BH | | Number of Individuals Covered | 71 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $333,113 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 302225 |
| Policy instance | 2 |
| Insurance contract or identification number | 302225 | | Number of Individuals Covered | 87 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $333 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $2,419 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $333 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
| Policy contract number | 5967858 |
| Policy instance | 3 |
| Insurance contract or identification number | 5967858 | | Number of Individuals Covered | 510 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $30,297 | | Total amount of fees paid to insurance company | USD $6,800 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $273,779 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $30,297 | | Amount paid for insurance broker fees | 6800 | | Additional information about fees paid to insurance broker | SUPPLEMENTAL COMPENSATION, NON-MONETARY COMPENSATION, NON-MONETARY COMPENSATION | | Insurance broker organization code? | 3 |
|
| AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 ) |
| Policy contract number | 29275 |
| Policy instance | 4 |
| Insurance contract or identification number | 29275 | | Number of Individuals Covered | 81 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $11,762 | | Total amount of fees paid to insurance company | USD $988 | | 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 | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Welfare Benefit Premiums Paid to Carrier | USD $191,640 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $9,441 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Additional information about fees paid to insurance broker | TOTAL FEES PAID |
|
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
| Policy contract number | 232318 |
| Policy instance | 5 |
| Insurance contract or identification number | 232318 | | Number of Individuals Covered | 259 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $93,837 | | Total amount of fees paid to insurance company | USD $538 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Welfare Benefit Premiums Paid to Carrier | USD $2,028,673 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $93,837 | | Amount paid for insurance broker fees | 538 | | Additional information about fees paid to insurance broker | LBG BOB BONUS | | Insurance broker organization code? | 3 |
|
| KAISER FOUNDATION HEALTH PLAN OF COLORADO (National Association of Insurance Commissioners NAIC id number: 95669 ) |
| Policy contract number | 35943 |
| Policy instance | 6 |
| Insurance contract or identification number | 35943 | | Number of Individuals Covered | 215 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $36,505 | | Total amount of fees paid to insurance company | USD $1,745 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $904,329 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $36,505 | | Amount paid for insurance broker fees | 1745 | | Additional information about fees paid to insurance broker | LGB BOB BONUS | | Insurance broker organization code? | 3 |
|
| AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 ) |
| Policy contract number | 66236 |
| Policy instance | 13 |
| Insurance contract or identification number | 66236 | | Number of Individuals Covered | 47 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $3,303 | | Total amount of fees paid to insurance company | USD $930 | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENT, CANCER, CRITICAL ILLNESS | | Welfare Benefit Premiums Paid to Carrier | USD $80,260 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,740 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 930 | | Additional information about fees paid to insurance broker | TOTAL FEES PAID |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 302225 |
| Policy instance | 1 |
| Insurance contract or identification number | 302225 | | Number of Individuals Covered | 91 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $754 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $2,969 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $754 | | Insurance broker organization code? | 3 |
|
| AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 ) |
| Policy contract number | 29275 |
| Policy instance | 11 |
| Insurance contract or identification number | 29275 | | Number of Individuals Covered | 122 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $3,125 | | Total amount of fees paid to insurance company | USD $0 | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENT, CANCER, CRITICAL ILLNESS | | Welfare Benefit Premiums Paid to Carrier | USD $153,984 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,495 | | Insurance broker organization code? | 3 |
|
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 0108903 |
| Policy instance | 10 |
| Insurance contract or identification number | 0108903 | | Number of Individuals Covered | 50 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $355,831 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 ) |
| Policy contract number | 48231 |
| Policy instance | 9 |
| Insurance contract or identification number | 48231 | | Number of Individuals Covered | 5 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $-120 | | Total amount of fees paid to insurance company | USD $0 | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENT | | Welfare Benefit Premiums Paid to Carrier | USD $6,687 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $335 | | Insurance broker organization code? | 3 |
|
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
| Policy contract number | 232318 |
| Policy instance | 12 |
| Insurance contract or identification number | 232318 | | Number of Individuals Covered | 274 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $58,899 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,177,048 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $58,899 | | Insurance broker organization code? | 3 |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 1018120100 |
| Policy instance | 8 |
| Insurance contract or identification number | 1018120100 | | Number of Individuals Covered | 635 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $4,308 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $43,023 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,308 | | Insurance broker organization code? | 3 |
|
| BANNER HEALTH AND AETNA HEALTH (National Association of Insurance Commissioners NAIC id number: 16058 ) |
| Policy contract number | 0108903BH |
| Policy instance | 7 |
| Insurance contract or identification number | 0108903BH | | Number of Individuals Covered | 87 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $330,885 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 ) |
| Policy contract number | 29126 |
| Policy instance | 5 |
| Insurance contract or identification number | 29126 | | Number of Individuals Covered | 17 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $1,800 | | Total amount of fees paid to insurance company | USD $304 | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENT, CANCER, CRITICAL ILLNESS | | Welfare Benefit Premiums Paid to Carrier | USD $28,917 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,390 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 304 | | Additional information about fees paid to insurance broker | TOTAL FEES PAID |
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| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
| Policy contract number | KM05956091 |
| Policy instance | 4 |
| Insurance contract or identification number | KM05956091 | | Number of Individuals Covered | 1045 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $20,613 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $224,026 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $20,613 | | Insurance broker organization code? | 3 |
|
| AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 ) |
| Policy contract number | 98473 |
| Policy instance | 3 |
| Insurance contract or identification number | 98473 | | Number of Individuals Covered | 46 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $3,750 | | Total amount of fees paid to insurance company | USD $700 | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENT, CANCER, CRITICAL ILLNESS | | Welfare Benefit Premiums Paid to Carrier | USD $59,493 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,912 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 700 | | Additional information about fees paid to insurance broker | TOTAL FEES PAID |
|
| AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 ) |
| Policy contract number | 93682 |
| Policy instance | 2 |
| Insurance contract or identification number | 93682 | | Number of Individuals Covered | 34 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $1,744 | | Total amount of fees paid to insurance company | USD $811 | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT, CANCER, ACCIDENT, CRITICAL ILLNESS, INDIVIDUAL HI | | Welfare Benefit Premiums Paid to Carrier | USD $45,685 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,744 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 811 | | Additional information about fees paid to insurance broker | TOTAL FEES PAID |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 1018120100 |
| Policy instance | 9 |
| Insurance contract or identification number | 1018120100 | | Number of Individuals Covered | 707 | | Insurance policy start date | 2018-09-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $1,236 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $15,194 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,236 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUC 0BB5J |
| Policy instance | 18 |
| Insurance contract or identification number | GUC 0BB5J | | Number of Individuals Covered | 204 | | Insurance policy start date | 2018-02-01 | | Insurance policy end date | 2018-08-31 | | Total amount of commissions paid to insurance broker | USD $4,519 | | Total amount of fees paid to insurance company | USD $0 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $30,128 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,519 | | Insurance broker organization code? | 3 |
|
| AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 ) |
| Policy contract number | 66236 |
| Policy instance | 17 |
| Insurance contract or identification number | 66236 | | Number of Individuals Covered | 48 | | Insurance policy start date | 2018-09-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $1,893 | | Total amount of fees paid to insurance company | USD $223 | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENT, CANCER, CRITICAL ILLNESS | | Welfare Benefit Premiums Paid to Carrier | USD $17,819 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,035 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 223 | | Additional information about fees paid to insurance broker | TOTAL FEES PAID |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GVTL0BB5J |
| Policy instance | 16 |
| Insurance contract or identification number | GVTL0BB5J | | Number of Individuals Covered | 480 | | Insurance policy start date | 2018-02-01 | | Insurance policy end date | 2018-08-31 | | Total amount of commissions paid to insurance broker | USD $5,207 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | VOLUNTARY ACCIDENTAL DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $34,711 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,207 | | Insurance broker organization code? | 3 |
|
| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) |
| Policy contract number | 232318 |
| Policy instance | 15 |
| Insurance contract or identification number | 232318 | | Number of Individuals Covered | 275 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $53,284 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $991,243 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $53,293 | | Insurance broker organization code? | 3 |
|
| AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 ) |
| Policy contract number | 98473 |
| Policy instance | 2 |
| Insurance contract or identification number | 98473 | | Number of Individuals Covered | 47 | | Insurance policy start date | 2018-09-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $1,925 | | Total amount of fees paid to insurance company | USD $184 | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENT, CANCER, CRITICAL ILLNESS | | Welfare Benefit Premiums Paid to Carrier | USD $16,275 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,129 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 184 | | Additional information about fees paid to insurance broker | TOTAL FEES PAID |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 303799 |
| Policy instance | 3 |
| Insurance contract or identification number | 303799 | | Number of Individuals Covered | 368 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-01-31 | | Total amount of commissions paid to insurance broker | USD $544 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $3,822 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $544 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUDH0BB5J |
| Policy instance | 4 |
| Insurance contract or identification number | GUDH0BB5J | | Number of Individuals Covered | 179 | | Insurance policy start date | 2018-02-01 | | Insurance policy end date | 2018-08-31 | | Total amount of commissions paid to insurance broker | USD $1,835 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | VOLUNTARY ACCIDENT | | Welfare Benefit Premiums Paid to Carrier | USD $12,233 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,835 | | Insurance broker organization code? | 3 |
|
| AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 ) |
| Policy contract number | 29126 |
| Policy instance | 5 |
| Insurance contract or identification number | 29126 | | Number of Individuals Covered | 12 | | Insurance policy start date | 2018-09-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $691 | | Total amount of fees paid to insurance company | USD $70 | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENT, CANCER, CRITICAL ILLNESS | | Welfare Benefit Premiums Paid to Carrier | USD $6,800 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $364 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 70 | | Additional information about fees paid to insurance broker | TOTAL FEES PAID |
|
| KAISER FOUNDATION HEALTH PLAN OF COLORADO (National Association of Insurance Commissioners NAIC id number: 95669 ) |
| Policy contract number | 35943 |
| Policy instance | 6 |
| Insurance contract or identification number | 35943 | | Number of Individuals Covered | 185 | | Insurance policy start date | 2018-09-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $10,534 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $315,900 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $10,534 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUPR0BB5J |
| Policy instance | 7 |
| Insurance contract or identification number | GUPR0BB5J | | Number of Individuals Covered | 239 | | Insurance policy start date | 2018-02-01 | | Insurance policy end date | 2018-08-31 | | Total amount of commissions paid to insurance broker | USD $7,505 | | Total amount of fees paid to insurance company | USD $0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $50,031 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,505 | | Insurance broker organization code? | 3 |
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| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 0755947 |
| Policy instance | 8 |
| Insurance contract or identification number | 0755947 | | Number of Individuals Covered | 704 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-01-31 | | Total amount of commissions paid to insurance broker | USD $4,333 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $82,186 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,545 | | Insurance broker organization code? | 3 |
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| AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 ) |
| Policy contract number | 48231 |
| Policy instance | 10 |
| Insurance contract or identification number | 48231 | | Number of Individuals Covered | 14 | | Insurance policy start date | 2018-09-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $211 | | Total amount of fees paid to insurance company | USD $0 | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENT | | Welfare Benefit Premiums Paid to Carrier | USD $4,304 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $215 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG0BB5J |
| Policy instance | 11 |
| Insurance contract or identification number | GLUG0BB5J | | Number of Individuals Covered | 1240 | | Insurance policy start date | 2018-02-01 | | Insurance policy end date | 2018-08-31 | | Total amount of commissions paid to insurance broker | USD $2,567 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $17,116 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,567 | | Insurance broker organization code? | 3 |
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| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 302225 |
| Policy instance | 12 |
| Insurance contract or identification number | 302225 | | Number of Individuals Covered | 98 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $119 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $3,088 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $119 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUDE0BB5J |
| Policy instance | 13 |
| Insurance contract or identification number | GUDE0BB5J | | Number of Individuals Covered | 165 | | Insurance policy start date | 2018-02-01 | | Insurance policy end date | 2018-08-31 | | Total amount of commissions paid to insurance broker | USD $871 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | VOLUNTARY CRITICAL ILLNESS | | Welfare Benefit Premiums Paid to Carrier | USD $8,714 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $871 | | Insurance broker organization code? | 3 |
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| AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 ) |
| Policy contract number | 29275 |
| Policy instance | 14 |
| Insurance contract or identification number | 29275 | | Number of Individuals Covered | 137 | | Insurance policy start date | 2018-09-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $3,240 | | Total amount of fees paid to insurance company | USD $0 | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENT, CANCER, CRITICAL ILLNESS | | Welfare Benefit Premiums Paid to Carrier | USD $54,551 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,645 | | Insurance broker organization code? | 3 |
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| AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 ) |
| Policy contract number | 93682 |
| Policy instance | 1 |
| Insurance contract or identification number | 93682 | | Number of Individuals Covered | 46 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $1,869 | | Total amount of fees paid to insurance company | USD $1,012 | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT, CANCER, ACCIDENT, CRITICAL ILLNESS, INDIVIDUAL HI | | Welfare Benefit Premiums Paid to Carrier | USD $63,937 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,869 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 1012 | | Additional information about fees paid to insurance broker | TOTAL FEES PAID |
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