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NORTHERN MONTANA HOSPITAL HEALTH PLAN 401k Plan overview

Plan NameNORTHERN MONTANA HOSPITAL HEALTH PLAN
Plan identification number 503

NORTHERN MONTANA HOSPITAL HEALTH PLAN Benefits

401k Plan TypeWelfare Benefit
Plan Features/Benefits
  • Health (other than dental or vision)
  • Life insurance
  • Long-term disability cover
  • Other welfare benefit cover

401k Sponsoring company profile

NORTHERN MONTANA HOSPITAL has sponsored the creation of one or more 401k plans.

Company Name:NORTHERN MONTANA HOSPITAL
Employer identification number (EIN):810231787
NAIC Classification:622000
NAIC Description: Hospitals

Form 5500 Filing Information

Submission information for form 5500 for 401k plan NORTHERN MONTANA HOSPITAL HEALTH PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5032022-01-01
5032021-01-01
5032020-01-01
5032019-01-01
5032018-01-01KIM LUCKE
5032017-01-01KIM LUCKE
5032016-01-01KIM LUCKE
5032015-01-01KIM LUCKE
5032014-01-01KIM LUCKE
5032013-01-01KIM LUCKE
5032012-01-01KIM LUCKE
5032011-01-01KIM LUCKE
5032009-01-01KIM LUCKE

Plan Statistics for NORTHERN MONTANA HOSPITAL HEALTH PLAN

401k plan membership statisitcs for NORTHERN MONTANA HOSPITAL HEALTH PLAN

Measure Date Value
2022: NORTHERN MONTANA HOSPITAL HEALTH PLAN 2022 401k membership
Total participants, beginning-of-year2022-01-01375
Total number of active participants reported on line 7a of the Form 55002022-01-01370
Number of retired or separated participants receiving benefits2022-01-010
Number of other retired or separated participants entitled to future benefits2022-01-010
Total of all active and inactive participants2022-01-01370
2021: NORTHERN MONTANA HOSPITAL HEALTH PLAN 2021 401k membership
Total participants, beginning-of-year2021-01-01184
Total number of active participants reported on line 7a of the Form 55002021-01-01165
Total of all active and inactive participants2021-01-01165
2020: NORTHERN MONTANA HOSPITAL HEALTH PLAN 2020 401k membership
Total participants, beginning-of-year2020-01-01204
Total number of active participants reported on line 7a of the Form 55002020-01-01189
Total of all active and inactive participants2020-01-01189
2019: NORTHERN MONTANA HOSPITAL HEALTH PLAN 2019 401k membership
Total participants, beginning-of-year2019-01-01207
Total number of active participants reported on line 7a of the Form 55002019-01-01202
Total of all active and inactive participants2019-01-01202
2018: NORTHERN MONTANA HOSPITAL HEALTH PLAN 2018 401k membership
Total participants, beginning-of-year2018-01-01251
Total number of active participants reported on line 7a of the Form 55002018-01-01209
Total of all active and inactive participants2018-01-01209
2017: NORTHERN MONTANA HOSPITAL HEALTH PLAN 2017 401k membership
Total participants, beginning-of-year2017-01-01220
Total number of active participants reported on line 7a of the Form 55002017-01-01208
Total of all active and inactive participants2017-01-01208
2016: NORTHERN MONTANA HOSPITAL HEALTH PLAN 2016 401k membership
Total participants, beginning-of-year2016-01-01209
Total number of active participants reported on line 7a of the Form 55002016-01-01203
Total of all active and inactive participants2016-01-01203
2015: NORTHERN MONTANA HOSPITAL HEALTH PLAN 2015 401k membership
Total participants, beginning-of-year2015-01-01245
Total number of active participants reported on line 7a of the Form 55002015-01-01213
Total of all active and inactive participants2015-01-01213
2014: NORTHERN MONTANA HOSPITAL HEALTH PLAN 2014 401k membership
Total participants, beginning-of-year2014-01-01264
Total number of active participants reported on line 7a of the Form 55002014-01-01237
Total of all active and inactive participants2014-01-01237
2013: NORTHERN MONTANA HOSPITAL HEALTH PLAN 2013 401k membership
Total participants, beginning-of-year2013-01-01252
Total number of active participants reported on line 7a of the Form 55002013-01-01250
Total of all active and inactive participants2013-01-01250
2012: NORTHERN MONTANA HOSPITAL HEALTH PLAN 2012 401k membership
Total participants, beginning-of-year2012-01-01222
Total number of active participants reported on line 7a of the Form 55002012-01-01236
Total of all active and inactive participants2012-01-01236
2011: NORTHERN MONTANA HOSPITAL HEALTH PLAN 2011 401k membership
Total participants, beginning-of-year2011-01-01221
Total number of active participants reported on line 7a of the Form 55002011-01-01209
Total of all active and inactive participants2011-01-01209
2009: NORTHERN MONTANA HOSPITAL HEALTH PLAN 2009 401k membership
Total participants, beginning-of-year2009-01-01238
Total number of active participants reported on line 7a of the Form 55002009-01-01229
Total of all active and inactive participants2009-01-01229

Form 5500 Responses for NORTHERN MONTANA HOSPITAL HEALTH PLAN

2022: NORTHERN MONTANA HOSPITAL HEALTH PLAN 2022 form 5500 responses
2022-01-01Type of plan entitySingle employer plan
2022-01-01Submission has been amendedNo
2022-01-01This submission is the final filingNo
2022-01-01This return/report is a short plan year return/report (less than 12 months)No
2022-01-01Plan is a collectively bargained planNo
2022-01-01Plan funding arrangement – InsuranceYes
2022-01-01Plan benefit arrangement – InsuranceYes
2021: NORTHERN MONTANA HOSPITAL HEALTH PLAN 2021 form 5500 responses
2021-01-01Type of plan entitySingle employer plan
2021-01-01Plan funding arrangement – InsuranceYes
2021-01-01Plan benefit arrangement – InsuranceYes
2020: NORTHERN MONTANA HOSPITAL HEALTH PLAN 2020 form 5500 responses
2020-01-01Type of plan entitySingle employer plan
2020-01-01Plan funding arrangement – InsuranceYes
2020-01-01Plan benefit arrangement – InsuranceYes
2019: NORTHERN MONTANA HOSPITAL HEALTH PLAN 2019 form 5500 responses
2019-01-01Type of plan entitySingle employer plan
2019-01-01Plan funding arrangement – InsuranceYes
2019-01-01Plan benefit arrangement – InsuranceYes
2018: NORTHERN MONTANA HOSPITAL HEALTH PLAN 2018 form 5500 responses
2018-01-01Type of plan entitySingle employer plan
2018-01-01Plan funding arrangement – InsuranceYes
2018-01-01Plan benefit arrangement – InsuranceYes
2017: NORTHERN MONTANA HOSPITAL HEALTH PLAN 2017 form 5500 responses
2017-01-01Type of plan entitySingle employer plan
2017-01-01Plan funding arrangement – InsuranceYes
2017-01-01Plan benefit arrangement – InsuranceYes
2016: NORTHERN MONTANA HOSPITAL HEALTH PLAN 2016 form 5500 responses
2016-01-01Type of plan entitySingle employer plan
2016-01-01Plan funding arrangement – InsuranceYes
2016-01-01Plan benefit arrangement – InsuranceYes
2015: NORTHERN MONTANA HOSPITAL HEALTH PLAN 2015 form 5500 responses
2015-01-01Type of plan entitySingle employer plan
2015-01-01Plan funding arrangement – InsuranceYes
2015-01-01Plan benefit arrangement – InsuranceYes
2014: NORTHERN MONTANA HOSPITAL HEALTH PLAN 2014 form 5500 responses
2014-01-01Type of plan entitySingle employer plan
2014-01-01Plan funding arrangement – InsuranceYes
2014-01-01Plan benefit arrangement – InsuranceYes
2013: NORTHERN MONTANA HOSPITAL HEALTH PLAN 2013 form 5500 responses
2013-01-01Type of plan entitySingle employer plan
2013-01-01Plan funding arrangement – InsuranceYes
2013-01-01Plan benefit arrangement – InsuranceYes
2012: NORTHERN MONTANA HOSPITAL HEALTH PLAN 2012 form 5500 responses
2012-01-01Type of plan entitySingle employer plan
2012-01-01Plan funding arrangement – InsuranceYes
2012-01-01Plan benefit arrangement – InsuranceYes
2011: NORTHERN MONTANA HOSPITAL HEALTH PLAN 2011 form 5500 responses
2011-01-01Type of plan entitySingle employer plan
2011-01-01Plan funding arrangement – InsuranceYes
2011-01-01Plan benefit arrangement – InsuranceYes
2009: NORTHERN MONTANA HOSPITAL HEALTH PLAN 2009 form 5500 responses
2009-01-01Type of plan entitySingle employer plan
2009-01-01This submission is the final filingNo
2009-01-01Plan funding arrangement – InsuranceYes
2009-01-01Plan benefit arrangement – InsuranceYes

Insurance Providers Used on plan

DELTA DENTAL PLAN OF ARKANSAS (National Association of Insurance Commissioners NAIC id number: 81396 )
Policy contract number06172
Policy instance 5
Insurance contract or identification number06172
Number of Individuals Covered288
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $10,060
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $100,600
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $10,060
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGVTL0BXTP
Policy instance 4
Insurance contract or identification numberGVTL0BXTP
Number of Individuals Covered63
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $4,291
Total amount of fees paid to insurance companyUSD $899
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&D VOLUNTARY
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $28,609
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,291
Amount paid for insurance broker fees899
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLUG0BXTP
Policy instance 3
Insurance contract or identification numberGLUG0BXTP
Number of Individuals Covered370
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $4,106
Total amount of fees paid to insurance companyUSD $1,955
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&D
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $52,560
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,106
Amount paid for insurance broker fees1955
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLTD0BXTP
Policy instance 2
Insurance contract or identification numberGLTD0BXTP
Number of Individuals Covered370
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $4,899
Total amount of fees paid to insurance companyUSD $3,103
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $82,901
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,899
Amount paid for insurance broker fees3103
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )
Policy contract number12A263
Policy instance 1
Insurance contract or identification number12A263
Number of Individuals Covered287
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $30,000
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $2,264,362
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $30,000
Insurance broker organization code?3
BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )
Policy contract number12A263
Policy instance 1
Insurance contract or identification number12A263
Number of Individuals Covered276
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $30,000
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $2,337,442
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $30,000
Insurance broker organization code?3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number908301
Policy instance 2
Insurance contract or identification number908301
Number of Individuals Covered416
Insurance policy start date2021-01-01
Insurance policy end date2021-09-01
Total amount of commissions paid to insurance brokerUSD $5,778
Total amount of fees paid to insurance companyUSD $663
Life Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $88,412
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,778
Amount paid for insurance broker fees663
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION PAID
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLTD0BXTP
Policy instance 3
Insurance contract or identification numberGLTD0BXTP
Number of Individuals Covered365
Insurance policy start date2021-09-01
Insurance policy end date2022-01-01
Total amount of commissions paid to insurance brokerUSD $2,669
Total amount of fees paid to insurance companyUSD $0
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $26,689
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,669
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLUG0BXTP
Policy instance 4
Insurance contract or identification numberGLUG0BXTP
Number of Individuals Covered365
Insurance policy start date2021-09-01
Insurance policy end date2022-01-01
Total amount of commissions paid to insurance brokerUSD $1,683
Total amount of fees paid to insurance companyUSD $0
Life Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $16,828
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,683
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGVTL0BXTP
Policy instance 5
Insurance contract or identification numberGVTL0BXTP
Number of Individuals Covered55
Insurance policy start date2021-09-01
Insurance policy end date2022-01-01
Total amount of commissions paid to insurance brokerUSD $1,198
Total amount of fees paid to insurance companyUSD $0
Life Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $7,984
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,198
Insurance broker organization code?3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number908302
Policy instance 6
Insurance contract or identification number908302
Number of Individuals Covered57
Insurance policy start date2021-01-01
Insurance policy end date2021-09-01
Total amount of commissions paid to insurance brokerUSD $2,459
Total amount of fees paid to insurance companyUSD $123
Life Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $16,431
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,459
Amount paid for insurance broker fees123
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION PAID
Insurance broker organization code?3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number908301
Policy instance 3
Insurance contract or identification number908301
Number of Individuals Covered419
Insurance policy start date2020-01-01
Insurance policy end date2021-01-01
Total amount of commissions paid to insurance brokerUSD $10,715
Total amount of fees paid to insurance companyUSD $1,493
Life Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $183,426
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $10,715
Amount paid for insurance broker fees1493
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION PAID
Insurance broker organization code?3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number908302
Policy instance 2
Insurance contract or identification number908302
Number of Individuals Covered64
Insurance policy start date2020-01-01
Insurance policy end date2021-01-01
Total amount of commissions paid to insurance brokerUSD $5,149
Total amount of fees paid to insurance companyUSD $258
Life Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $31,128
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,149
Amount paid for insurance broker fees258
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION PAID
Insurance broker organization code?3
BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )
Policy contract number12A263
Policy instance 1
Insurance contract or identification number12A263
Number of Individuals Covered299
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $30,000
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $2,613,505
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $30,000
Insurance broker organization code?3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number908302
Policy instance 2
Insurance contract or identification number908302
Number of Individuals Covered67
Insurance policy start date2019-01-01
Insurance policy end date2020-01-01
Total amount of commissions paid to insurance brokerUSD $5,054
Total amount of fees paid to insurance companyUSD $253
Life Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $34,077
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,054
Amount paid for insurance broker fees253
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION PAID
Insurance broker organization code?3
BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )
Policy contract number12A263
Policy instance 1
Insurance contract or identification number12A263
Number of Individuals Covered337
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $30,000
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $2,813,311
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $30,000
Insurance broker organization code?3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number908301
Policy instance 3
Insurance contract or identification number908301
Number of Individuals Covered437
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $8,731
Total amount of fees paid to insurance companyUSD $1,335
Life Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $178,826
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $8,731
Amount paid for insurance broker fees1335
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION PAID
Insurance broker organization code?3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number908302
Policy instance 3
Insurance contract or identification number908302
Number of Individuals Covered71
Insurance policy start date2018-01-01
Insurance policy end date2019-01-01
Total amount of commissions paid to insurance brokerUSD $5,341
Total amount of fees paid to insurance companyUSD $124
Life Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $38,385
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,857
Insurance broker organization code?3
Amount paid for insurance broker fees124
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION PAID
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number908301
Policy instance 2
Insurance contract or identification number908301
Number of Individuals Covered436
Insurance policy start date2018-01-01
Insurance policy end date2019-01-01
Total amount of commissions paid to insurance brokerUSD $8,596
Total amount of fees paid to insurance companyUSD $604
Life Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $179,550
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $7,145
Insurance broker organization code?3
Amount paid for insurance broker fees604
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION PAID
BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )
Policy contract number12A263
Policy instance 1
Insurance contract or identification number12A263
Number of Individuals Covered349
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $30,000
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $3,110,273
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $22,500
Insurance broker organization code?3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number908302
Policy instance 3
Insurance contract or identification number908302
Number of Individuals Covered88
Insurance policy start date2017-01-01
Insurance policy end date2018-01-01
Total amount of commissions paid to insurance brokerUSD $6,552
Total amount of fees paid to insurance companyUSD $0
Life Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $43,683
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6,552
Insurance broker organization code?3
Insurance broker nameSTEVEN MARIANI
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number908301
Policy instance 2
Insurance contract or identification number908301
Number of Individuals Covered471
Insurance policy start date2017-01-01
Insurance policy end date2018-01-01
Total amount of commissions paid to insurance brokerUSD $8,590
Total amount of fees paid to insurance companyUSD $0
Life Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $163,984
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $8,590
Insurance broker organization code?3
Insurance broker nameSTEVEN MARIANI
BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )
Policy contract number12A263
Policy instance 1
Insurance contract or identification number12A263
Number of Individuals Covered357
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $30,000
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $3,337,590
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $30,000
Insurance broker organization code?3
Insurance broker nameSTEVEN MARIANI
BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )
Policy contract number12A263
Policy instance 1
Insurance contract or identification number12A263
Number of Individuals Covered373
Insurance policy start date2015-01-01
Insurance policy end date2015-12-31
Total amount of commissions paid to insurance brokerUSD $32,500
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $3,079,176
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $32,500
Insurance broker organization code?3
Insurance broker nameSTEVEN MARIANI
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract numberGL 668960
Policy instance 2
Insurance contract or identification numberGL 668960
Number of Individuals Covered415
Insurance policy start date2015-01-01
Insurance policy end date2015-12-31
Total amount of commissions paid to insurance brokerUSD $3,851
Total amount of fees paid to insurance companyUSD $6,932
Life Insurance Welfare BenefitYes
Other welfare benefits providedDEPENDENT/SUPPLEMENTAL/AD&D
Welfare Benefit Premiums Paid to CarrierUSD $71,715
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,851
Amount paid for insurance broker fees6932
Additional information about fees paid to insurance brokerADMINISTRATIVE AND OTHER
Insurance broker organization code?3
Insurance broker nameGALLAGHER BENEFIT SERVICES INC
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract numberVAR 672930
Policy instance 3
Insurance contract or identification numberVAR 672930
Number of Individuals Covered110
Insurance policy start date2015-01-01
Insurance policy end date2015-12-31
Total amount of commissions paid to insurance brokerUSD $187
Total amount of fees paid to insurance companyUSD $337
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $3,464
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $187
Amount paid for insurance broker fees337
Additional information about fees paid to insurance brokerADMINISTRATIVE AND OTHER
Insurance broker organization code?3
Insurance broker nameGALLAGHER BENEFIT SERVICES INC
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract numberLTD 669915
Policy instance 4
Insurance contract or identification numberLTD 669915
Number of Individuals Covered415
Insurance policy start date2015-01-01
Insurance policy end date2015-12-31
Total amount of commissions paid to insurance brokerUSD $7,658
Total amount of fees paid to insurance companyUSD $13,784
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $142,326
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $7,658
Amount paid for insurance broker fees13784
Additional information about fees paid to insurance brokerADMINISTRATIVE AND OTHER
Insurance broker organization code?3
Insurance broker nameGALLAGHER BENEFIT SERVICES INC
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract numberG 670396
Policy instance 5
Insurance contract or identification numberG 670396
Number of Individuals Covered1
Insurance policy start date2015-01-01
Insurance policy end date2015-12-31
Total amount of commissions paid to insurance brokerUSD $54
Total amount of fees paid to insurance companyUSD $37
Other welfare benefits providedSHORT TERM DISABILITY
Welfare Benefit Premiums Paid to CarrierUSD $1,006
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $54
Amount paid for insurance broker fees37
Additional information about fees paid to insurance brokerADMINISTRATIVE AND OTHER
Insurance broker organization code?3
Insurance broker nameGALLAGHER BENEFIT SERVICES INC
BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )
Policy contract number12A263
Policy instance 1
Insurance contract or identification number12A263
Number of Individuals Covered179
Insurance policy start date2014-01-01
Insurance policy end date2014-12-31
Total amount of commissions paid to insurance brokerUSD $30,000
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,076,831
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $30,000
Insurance broker organization code?3
Insurance broker nameSTEVEN MARIANI
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract numberLTD 669915
Policy instance 4
Insurance contract or identification numberLTD 669915
Number of Individuals Covered409
Insurance policy start date2014-01-01
Insurance policy end date2014-12-31
Total amount of commissions paid to insurance brokerUSD $5,889
Total amount of fees paid to insurance companyUSD $10,601
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $117,789
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,889
Amount paid for insurance broker fees10601
Additional information about fees paid to insurance brokerADMINSTRATIVE AND OTHER
Insurance broker organization code?3
Insurance broker nameINSURANCE POINT LLC
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract numberVAR 672930
Policy instance 3
Insurance contract or identification numberVAR 672930
Number of Individuals Covered113
Insurance policy start date2014-01-01
Insurance policy end date2014-12-31
Total amount of commissions paid to insurance brokerUSD $112
Total amount of fees paid to insurance companyUSD $202
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $2,244
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $112
Amount paid for insurance broker fees202
Additional information about fees paid to insurance brokerADMINSTRATIVE AND OTHER
Insurance broker organization code?3
Insurance broker nameINSURANCE POINT LLC
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract numberGL 668960
Policy instance 2
Insurance contract or identification numberGL 668960
Number of Individuals Covered419
Insurance policy start date2014-01-01
Insurance policy end date2014-12-31
Total amount of commissions paid to insurance brokerUSD $3,106
Total amount of fees paid to insurance companyUSD $5,591
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Life Insurance Welfare BenefitYes
Other welfare benefits providedDEPENDENT/SUPPLEMENTAL/AD&D
Welfare Benefit Premiums Paid to CarrierUSD $62,120
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,106
Amount paid for insurance broker fees5591
Additional information about fees paid to insurance brokerADMINSTRATIVE AND OTHER
Insurance broker organization code?3
Insurance broker nameINSURANCE POINT LLC
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number119408
Policy instance 1
Insurance contract or identification number119408
Number of Individuals Covered435
Insurance policy start date2013-01-01
Insurance policy end date2013-12-31
Total amount of commissions paid to insurance brokerUSD $9,462
Total amount of fees paid to insurance companyUSD $2,973
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Life Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $237,878
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $9,462
Insurance broker organization code?5
Amount paid for insurance broker fees2973
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
Insurance broker namePEAK1 ADMINISTRATION LLC
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number1190409
Policy instance 2
Insurance contract or identification number1190409
Number of Individuals Covered101
Insurance policy start date2013-01-01
Insurance policy end date2013-12-31
Total amount of commissions paid to insurance brokerUSD $6,611
Total amount of fees paid to insurance companyUSD $551
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Life Insurance Welfare BenefitYes
Other welfare benefits providedLIFESTYLE AD&D
Welfare Benefit Premiums Paid to CarrierUSD $41,321
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6,611
Amount paid for insurance broker fees109
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
Insurance broker organization code?5
Insurance broker namePEAK1 ADMINISTRATION LLC
BLUE CROSS BLUE SHIELD OF MONTANA (National Association of Insurance Commissioners NAIC id number: 53686 )
Policy contract number12A263
Policy instance 3
Insurance contract or identification number12A263
Number of Individuals Covered252
Insurance policy start date2013-01-01
Insurance policy end date2013-12-31
Total amount of commissions paid to insurance brokerUSD $27,500
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Health Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $27,500
Insurance broker organization code?3
Insurance broker nameSTEVEN MARIANI
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number1190409
Policy instance 2
Insurance contract or identification number1190409
Number of Individuals Covered106
Insurance policy start date2012-01-01
Insurance policy end date2012-12-31
Total amount of commissions paid to insurance brokerUSD $4,542
Total amount of fees paid to insurance companyUSD $379
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Life Insurance Welfare BenefitYes
Other welfare benefits providedLIFESTYLE AD&D
Welfare Benefit Premiums Paid to CarrierUSD $35,837
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,542
Amount paid for insurance broker fees379
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
Insurance broker organization code?5
Insurance broker namePEAK1 ADMINISTRATION LLC
BLUE CROSS BLUE SHIELD OF MONTANA (National Association of Insurance Commissioners NAIC id number: 53686 )
Policy contract number12A263
Policy instance 3
Insurance contract or identification number12A263
Number of Individuals Covered240
Insurance policy start date2012-01-01
Insurance policy end date2012-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Health Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Insurance broker organization code?3
Insurance broker nameSTEVEN MARIANI
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number119408
Policy instance 1
Insurance contract or identification number119408
Number of Individuals Covered420
Insurance policy start date2012-01-01
Insurance policy end date2012-12-31
Total amount of commissions paid to insurance brokerUSD $8,435
Total amount of fees paid to insurance companyUSD $2,023
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Life Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $213,471
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $8,435
Amount paid for insurance broker fees2023
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
Insurance broker organization code?5
Insurance broker namePEAK1 ADMINISTRATION LLC
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number119408
Policy instance 2
Insurance contract or identification number119408
Number of Individuals Covered434
Insurance policy start date2011-01-01
Insurance policy end date2011-12-31
Total amount of commissions paid to insurance brokerUSD $9,039
Total amount of fees paid to insurance companyUSD $2,089
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Life Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $208,867
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
NEW WEST HEALTH SERVICES (National Association of Insurance Commissioners NAIC id number: 95829 )
Policy contract numberN000561
Policy instance 1
Insurance contract or identification numberN000561
Number of Individuals Covered413
Insurance policy start date2011-01-01
Insurance policy end date2011-12-31
Total amount of commissions paid to insurance brokerUSD $25,613
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $2,012,061
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
NEW WEST HEALTH SERVICES (National Association of Insurance Commissioners NAIC id number: 95829 )
Policy contract numberN000561
Policy instance 1
Insurance contract or identification numberN000561
Number of Individuals Covered420
Insurance policy start date2010-01-01
Insurance policy end date2010-12-31
Total amount of commissions paid to insurance brokerUSD $24,363
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,918,939
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number119408
Policy instance 2
Insurance contract or identification number119408
Number of Individuals Covered443
Insurance policy start date2010-01-01
Insurance policy end date2010-12-31
Total amount of commissions paid to insurance brokerUSD $9,032
Total amount of fees paid to insurance companyUSD $2,082
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Life Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $208,205
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No

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