GLOVER CHEVROLET WEST LLC has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan JIM GLOVER CHEVROLET WELFARE BENEFIT PLAN
| AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 ) |
| Policy contract number | 53998 |
| Policy instance | 8 |
| Insurance contract or identification number | 53998 | | Number of Individuals Covered | 32 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $10,085 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | CANCER | | Welfare Benefit Premiums Paid to Carrier | USD $37,112 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,900 | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL (National Association of Insurance Commissioners NAIC id number: 53937 ) |
| Policy contract number | 7668 |
| Policy instance | 1 |
| Insurance contract or identification number | 7668 | | Number of Individuals Covered | 118 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $8,287 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,287 | | Insurance broker organization code? | 3 |
|
| COMMUNITY CARE (National Association of Insurance Commissioners NAIC id number: 1001 ) |
| Policy contract number | D01327 |
| Policy instance | 2 |
| Insurance contract or identification number | D01327 | | Number of Individuals Covered | 163 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $29,020 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $823,109 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 29020 | | Additional information about fees paid to insurance broker | SERVICE FEE | | Insurance broker organization code? | 3 |
|
| AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 ) |
| Policy contract number | 66131 |
| Policy instance | 3 |
| Insurance contract or identification number | 66131 | | Number of Individuals Covered | 37 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $8,336 | | Total amount of fees paid to insurance company | USD $266 | | Health Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | CANCER | | Welfare Benefit Premiums Paid to Carrier | USD $78,760 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,283 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 266 | | 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 | 5127896 |
| Policy instance | 4 |
| Insurance contract or identification number | 5127896 | | Number of Individuals Covered | 186 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $2,347 | | Total amount of fees paid to insurance company | USD $39 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $14,850 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,296 | | Amount paid for insurance broker fees | 22 | | Additional information about fees paid to insurance broker | SUPPLEMENTAL COMPENSATION | | Insurance broker organization code? | 3 |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 30073721 |
| Policy instance | 5 |
| Insurance contract or identification number | 30073721 | | Number of Individuals Covered | 92 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $1,413 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $14,083 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,413 | | Insurance broker organization code? | 3 |
|
| AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 ) |
| Policy contract number | 29187 |
| Policy instance | 6 |
| Insurance contract or identification number | 29187 | | Number of Individuals Covered | 23 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $6,093 | | Total amount of fees paid to insurance company | USD $94 | | Health Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $34,522 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,591 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 94 | | Additional information about fees paid to insurance broker | FEES |
|
| AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 ) |
| Policy contract number | 54014 |
| Policy instance | 7 |
| Insurance contract or identification number | 54014 | | Number of Individuals Covered | 29 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $6,447 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | CANCER | | Welfare Benefit Premiums Paid to Carrier | USD $20,313 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,395 | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL (National Association of Insurance Commissioners NAIC id number: 53937 ) |
| Policy contract number | 7668 |
| Policy instance | 1 |
| Insurance contract or identification number | 7668 | | Number of Individuals Covered | 133 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $7,568 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,568 | | Insurance broker organization code? | 3 |
|
| COMMUNITY CARE (National Association of Insurance Commissioners NAIC id number: 1001 ) |
| Policy contract number | D01327 |
| Policy instance | 2 |
| Insurance contract or identification number | D01327 | | Number of Individuals Covered | 188 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $28,880 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $882,603 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 28880 | | Additional information about fees paid to insurance broker | SERVICE FEE | | Insurance broker organization code? | 3 |
|
| AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 ) |
| Policy contract number | 66131 |
| Policy instance | 3 |
| Insurance contract or identification number | 66131 | | Number of Individuals Covered | 37 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $6,144 | | Total amount of fees paid to insurance company | USD $259 | | Health Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | CANCER | | Welfare Benefit Premiums Paid to Carrier | USD $69,202 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,332 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 259 |
|
| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
| Policy contract number | 5127896 |
| Policy instance | 4 |
| Insurance contract or identification number | 5127896 | | Number of Individuals Covered | 233 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $2,581 | | Total amount of fees paid to insurance company | USD $168 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $17,507 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,325 | | Amount paid for insurance broker fees | 151 | | Additional information about fees paid to insurance broker | NON-MONETARY COMPENSATION | | Insurance broker organization code? | 3 |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 30073721 |
| Policy instance | 5 |
| Insurance contract or identification number | 30073721 | | Number of Individuals Covered | 100 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $1,316 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $13,430 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,316 | | Insurance broker organization code? | 3 |
|
| AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 ) |
| Policy contract number | 29187 |
| Policy instance | 6 |
| Insurance contract or identification number | 29187 | | Number of Individuals Covered | 14 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $4,309 | | Total amount of fees paid to insurance company | USD $72 | | Health Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | CANCER | | Welfare Benefit Premiums Paid to Carrier | USD $21,017 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,346 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 72 |
|
| AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 ) |
| Policy contract number | 54014 |
| Policy instance | 7 |
| Insurance contract or identification number | 54014 | | Number of Individuals Covered | 35 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $13,044 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | CANCER | | Welfare Benefit Premiums Paid to Carrier | USD $20,453 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $9,186 | | Insurance broker organization code? | 3 |
|
| AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 ) |
| Policy contract number | 53998 |
| Policy instance | 8 |
| Insurance contract or identification number | 53998 | | Number of Individuals Covered | 34 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $25,679 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | CANCER | | Welfare Benefit Premiums Paid to Carrier | USD $35,876 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $17,748 | | Insurance broker organization code? | 3 |
|
| AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 ) |
| Policy contract number | 29187 |
| Policy instance | 6 |
| Insurance contract or identification number | 29187 | | Number of Individuals Covered | 21 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $1,255 | | Total amount of fees paid to insurance company | USD $82 | | Health Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | CANCER | | Welfare Benefit Premiums Paid to Carrier | USD $19,942 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $790 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 82 |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 30073721 |
| Policy instance | 5 |
| Insurance contract or identification number | 30073721 | | Number of Individuals Covered | 83 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $820 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $10,040 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $820 | | Insurance broker organization code? | 3 |
|
| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
| Policy contract number | 5127896 |
| Policy instance | 4 |
| Insurance contract or identification number | 5127896 | | Number of Individuals Covered | 199 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $1,998 | | Total amount of fees paid to insurance company | USD $37 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $12,595 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,092 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 37 | | Additional information about fees paid to insurance broker | NON-MONETARY COMPENSATION |
|
| AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 ) |
| Policy contract number | 66131 |
| Policy instance | 3 |
| Insurance contract or identification number | 66131 | | Number of Individuals Covered | 58 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $3,095 | | Total amount of fees paid to insurance company | USD $392 | | Health Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | CANCER | | Welfare Benefit Premiums Paid to Carrier | USD $63,273 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,063 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 392 |
|
| COMMUNITY CARE (National Association of Insurance Commissioners NAIC id number: 1001 ) |
| Policy contract number | D01327 |
| Policy instance | 2 |
| Insurance contract or identification number | D01327 | | Number of Individuals Covered | 191 | | 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 $22,320 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $711,524 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 22320 | | Additional information about fees paid to insurance broker | SERVICE FEE | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL (National Association of Insurance Commissioners NAIC id number: 53937 ) |
| Policy contract number | 7668 |
| Policy instance | 1 |
| Insurance contract or identification number | 7668 | | Number of Individuals Covered | 104 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $4,839 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,839 | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL (National Association of Insurance Commissioners NAIC id number: 53937 ) |
| Policy contract number | 7668 |
| Policy instance | 1 |
| Insurance contract or identification number | 7668 | | Number of Individuals Covered | 96 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $4,154 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,154 | | Insurance broker organization code? | 3 |
|
| COMMUNITY CARE (National Association of Insurance Commissioners NAIC id number: 1001 ) |
| Policy contract number | D01327 |
| Policy instance | 2 |
| Insurance contract or identification number | D01327 | | Number of Individuals Covered | 138 | | 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 $19,660 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $627,929 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 19660 | | Additional information about fees paid to insurance broker | SERVICE FEE | | Insurance broker organization code? | 3 |
|
| AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 ) |
| Policy contract number | 66131 |
| Policy instance | 3 |
| Insurance contract or identification number | 66131 | | 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 $5,275 | | Total amount of fees paid to insurance company | USD $487 | | Health Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | CANCER | | Welfare Benefit Premiums Paid to Carrier | USD $52,976 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,906 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 487 |
|
| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
| Policy contract number | TS05127896 |
| Policy instance | 4 |
| Insurance contract or identification number | TS05127896 | | Number of Individuals Covered | 178 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $1,895 | | Total amount of fees paid to insurance company | USD $22 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $11,006 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,491 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 22 | | Additional information about fees paid to insurance broker | NON-MONETARY COMPENSATION |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 30073721 |
| Policy instance | 5 |
| Insurance contract or identification number | 30073721 | | Number of Individuals Covered | 60 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $628 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $6,457 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $628 | | Insurance broker organization code? | 3 |
|
| AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 ) |
| Policy contract number | 29187 |
| Policy instance | 6 |
| Insurance contract or identification number | 29187 | | Number of Individuals Covered | 15 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $2,050 | | Total amount of fees paid to insurance company | USD $54 | | Health Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | CANCER | | Welfare Benefit Premiums Paid to Carrier | USD $11,697 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,563 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 54 |
|
| AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 ) |
| Policy contract number | 29187 |
| Policy instance | 6 |
| Insurance contract or identification number | 29187 | | Number of Individuals Covered | 15 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $-813 | | Total amount of fees paid to insurance company | USD $44 | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | CANCER | | Welfare Benefit Premiums Paid to Carrier | USD $9,488 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $393 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 44 |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 30073721 |
| Policy instance | 5 |
| Insurance contract or identification number | 30073721 | | Number of Individuals Covered | 53 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $718 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $7,181 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $718 | | Insurance broker organization code? | 3 |
|
| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
| Policy contract number | TS05127896 |
| Policy instance | 4 |
| Insurance contract or identification number | TS05127896 | | Number of Individuals Covered | 149 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $817 | | Total amount of fees paid to insurance company | USD $24 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $8,175 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $573 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 24 | | Additional information about fees paid to insurance broker | NON-MONETARY COMPENSATION |
|
| AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 ) |
| Policy contract number | 66131 |
| Policy instance | 3 |
| Insurance contract or identification number | 66131 | | Number of Individuals Covered | 44 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $3,290 | | Total amount of fees paid to insurance company | USD $562 | | Health Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | CANCER | | Welfare Benefit Premiums Paid to Carrier | USD $49,777 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,488 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 562 |
|
| COMMUNITY CARE (National Association of Insurance Commissioners NAIC id number: 1001 ) |
| Policy contract number | D01327 |
| Policy instance | 2 |
| Insurance contract or identification number | D01327 | | Number of Individuals Covered | 126 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $19,820 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $599,933 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 19820 | | Additional information about fees paid to insurance broker | SERVICE FEE | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL (National Association of Insurance Commissioners NAIC id number: 53937 ) |
| Policy contract number | 7668 |
| Policy instance | 1 |
| Insurance contract or identification number | 7668 | | Number of Individuals Covered | 83 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $3,470 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,470 | | Insurance broker organization code? | 3 |
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