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DEARBORN HOLDING COMPANY, LLC EMPLOYEE BENEFIT PLAN 401k Plan overview

Plan NameDEARBORN HOLDING COMPANY, LLC EMPLOYEE BENEFIT PLAN
Plan identification number 501

DEARBORN HOLDING COMPANY, LLC EMPLOYEE BENEFIT PLAN Benefits

401k Plan TypeWelfare Benefit
Plan Features/Benefits
  • Health (other than dental or vision)
  • Life insurance
  • Dental
  • Vision
  • Long-term disability cover
  • Death benefits (include travel accident but not life insurance)
  • Other welfare benefit cover

401k Sponsoring company profile

DEARBORN HOLDING COMPANY, LLC has sponsored the creation of one or more 401k plans.

Company Name:DEARBORN HOLDING COMPANY, LLC
Employer identification number (EIN):811151147
NAIC Classification:238900

Additional information about DEARBORN HOLDING COMPANY, LLC

Jurisdiction of Incorporation: State of Delaware Division of Corporations
Incorporation Date:
Company Identification Number: 5934294

More information about DEARBORN HOLDING COMPANY, LLC

Form 5500 Filing Information

Submission information for form 5500 for 401k plan DEARBORN HOLDING COMPANY, LLC EMPLOYEE BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5012022-01-01
5012021-01-01
5012020-01-01
5012019-01-01
5012018-01-01KELLY SCHAFER
5012017-01-01KELLY SCHAFER
5012016-01-01KELLY SCHAFER

Plan Statistics for DEARBORN HOLDING COMPANY, LLC EMPLOYEE BENEFIT PLAN

401k plan membership statisitcs for DEARBORN HOLDING COMPANY, LLC EMPLOYEE BENEFIT PLAN

Measure Date Value
2022: DEARBORN HOLDING COMPANY, LLC EMPLOYEE BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year2022-01-01289
Total number of active participants reported on line 7a of the Form 55002022-01-01319
Number of retired or separated participants receiving benefits2022-01-013
Number of other retired or separated participants entitled to future benefits2022-01-010
Total of all active and inactive participants2022-01-01322
2021: DEARBORN HOLDING COMPANY, LLC EMPLOYEE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year2021-01-01243
Total number of active participants reported on line 7a of the Form 55002021-01-01285
Number of retired or separated participants receiving benefits2021-01-013
Number of other retired or separated participants entitled to future benefits2021-01-010
Total of all active and inactive participants2021-01-01288
2020: DEARBORN HOLDING COMPANY, LLC EMPLOYEE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year2020-01-01269
Total number of active participants reported on line 7a of the Form 55002020-01-01240
Number of retired or separated participants receiving benefits2020-01-017
Number of other retired or separated participants entitled to future benefits2020-01-010
Total of all active and inactive participants2020-01-01247
2019: DEARBORN HOLDING COMPANY, LLC EMPLOYEE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year2019-01-01267
Total number of active participants reported on line 7a of the Form 55002019-01-01263
Number of retired or separated participants receiving benefits2019-01-016
Number of other retired or separated participants entitled to future benefits2019-01-010
Total of all active and inactive participants2019-01-01269
2018: DEARBORN HOLDING COMPANY, LLC EMPLOYEE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year2018-01-01249
Total number of active participants reported on line 7a of the Form 55002018-01-01263
Number of retired or separated participants receiving benefits2018-01-014
Number of other retired or separated participants entitled to future benefits2018-01-010
Total of all active and inactive participants2018-01-01267
2017: DEARBORN HOLDING COMPANY, LLC EMPLOYEE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year2017-01-01253
Total number of active participants reported on line 7a of the Form 55002017-01-01246
Number of retired or separated participants receiving benefits2017-01-017
Number of other retired or separated participants entitled to future benefits2017-01-010
Total of all active and inactive participants2017-01-01253
2016: DEARBORN HOLDING COMPANY, LLC EMPLOYEE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year2016-01-01136
Total number of active participants reported on line 7a of the Form 55002016-01-01127
Number of retired or separated participants receiving benefits2016-01-018
Number of other retired or separated participants entitled to future benefits2016-01-010
Total of all active and inactive participants2016-01-01135

Form 5500 Responses for DEARBORN HOLDING COMPANY, LLC EMPLOYEE BENEFIT PLAN

2022: DEARBORN HOLDING COMPANY, LLC EMPLOYEE BENEFIT PLAN 2022 form 5500 responses
2022-01-01Type of plan entitySingle employer plan
2022-01-01Plan funding arrangement – InsuranceYes
2022-01-01Plan funding arrangement – General assets of the sponsorYes
2022-01-01Plan benefit arrangement – InsuranceYes
2022-01-01Plan benefit arrangement – General assets of the sponsorYes
2021: DEARBORN HOLDING COMPANY, LLC EMPLOYEE BENEFIT PLAN 2021 form 5500 responses
2021-01-01Type of plan entitySingle employer plan
2021-01-01Plan funding arrangement – InsuranceYes
2021-01-01Plan funding arrangement – General assets of the sponsorYes
2021-01-01Plan benefit arrangement – InsuranceYes
2021-01-01Plan benefit arrangement – General assets of the sponsorYes
2020: DEARBORN HOLDING COMPANY, LLC EMPLOYEE BENEFIT 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: DEARBORN HOLDING COMPANY, LLC EMPLOYEE BENEFIT 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: DEARBORN HOLDING COMPANY, LLC EMPLOYEE BENEFIT 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: DEARBORN HOLDING COMPANY, LLC EMPLOYEE BENEFIT 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: DEARBORN HOLDING COMPANY, LLC EMPLOYEE BENEFIT 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

Insurance Providers Used on plan

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number444750
Policy instance 8
Insurance contract or identification number444750
Number of Individuals Covered120
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $12,002
Total amount of fees paid to insurance companyUSD $1,283
Life Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $80,010
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $12,002
Amount paid for insurance broker fees1283
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
Insurance broker organization code?3
HEALTH ALLIANCE PLAN (National Association of Insurance Commissioners NAIC id number: 95844 )
Policy contract number10002562
Policy instance 1
Insurance contract or identification number10002562
Number of Individuals Covered68
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $19,884
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $452,037
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $14,278
Insurance broker organization code?3
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract numberETB131007
Policy instance 2
Insurance contract or identification numberETB131007
Number of Individuals Covered283
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $319
Other welfare benefits providedBUSINESS TRAVEL ACCIDENT
Welfare Benefit Premiums Paid to CarrierUSD $2,125
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $319
Insurance broker organization code?3
FOUR EVER LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80985 )
Policy contract number4EL-6656
Policy instance 3
Insurance contract or identification number4EL-6656
Number of Individuals Covered357
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $464
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $3,091
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $464
Insurance broker organization code?3
BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 )
Policy contract number286856
Policy instance 4
Insurance contract or identification number286856
Number of Individuals Covered355
Insurance policy start date2021-06-01
Insurance policy end date2022-05-31
Total amount of commissions paid to insurance brokerUSD $11,346
Total amount of fees paid to insurance companyUSD $50,317
Welfare Benefit Premiums Paid to CarrierUSD $257,516
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $11,346
Amount paid for insurance broker fees48541
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
PRE-PAID LEGAL SERVICES DBA LEGAL SHIELD (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number202926
Policy instance 5
Insurance contract or identification number202926
Number of Individuals Covered94
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $2,643
Other welfare benefits providedLEGAL
Welfare Benefit Premiums Paid to CarrierUSD $13,669
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,392
Insurance broker organization code?4
STARMOUNT LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68985 )
Policy contract number609220
Policy instance 6
Insurance contract or identification number609220
Number of Individuals Covered240
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $20,648
Total amount of fees paid to insurance companyUSD $2,620
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $201,122
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $20,648
Amount paid for insurance broker fees2620
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
Insurance broker organization code?3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number444751
Policy instance 7
Insurance contract or identification number444751
Number of Individuals Covered280
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $8,654
Total amount of fees paid to insurance companyUSD $1,906
Life Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $116,817
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $8,654
Amount paid for insurance broker fees1906
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
Insurance broker organization code?3
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number97454151001
Policy instance 1
Insurance contract or identification number97454151001
Number of Individuals Covered338
Insurance policy start date2021-01-01
Insurance policy end date2021-05-31
Total amount of commissions paid to insurance brokerUSD $948
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $11,341
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $948
Insurance broker organization code?3
HEALTH ALLIANCE PLAN (National Association of Insurance Commissioners NAIC id number: 95844 )
Policy contract number10002562
Policy instance 2
Insurance contract or identification number10002562
Number of Individuals Covered64
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $19,398
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $454,166
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $19,398
Insurance broker organization code?3
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract numberETB131007
Policy instance 3
Insurance contract or identification numberETB131007
Number of Individuals Covered254
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $319
Other welfare benefits providedBUSINESS TRAVEL ACCIDENT
Welfare Benefit Premiums Paid to CarrierUSD $2,125
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $319
Insurance broker organization code?3
FOUR EVER LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80985 )
Policy contract number4EL-6656
Policy instance 4
Insurance contract or identification number4EL-6656
Number of Individuals Covered311
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $473
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $3,154
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $473
Insurance broker organization code?3
BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 )
Policy contract number286856
Policy instance 5
Insurance contract or identification number286856
Number of Individuals Covered301
Insurance policy start date2020-06-01
Insurance policy end date2021-05-31
Total amount of commissions paid to insurance brokerUSD $10,220
Total amount of fees paid to insurance companyUSD $43,731
Welfare Benefit Premiums Paid to CarrierUSD $318,640
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $10,220
Amount paid for insurance broker fees42981
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
PRE-PAID LEGAL SERVICES DBA LEGAL SHIELD (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number202926
Policy instance 6
Insurance contract or identification number202926
Number of Individuals Covered86
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $1,905
Other welfare benefits providedLEGAL
Welfare Benefit Premiums Paid to CarrierUSD $12,422
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $956
Insurance broker organization code?4
STARMOUNT LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68985 )
Policy contract number609220
Policy instance 7
Insurance contract or identification number609220
Number of Individuals Covered206
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $16,854
Total amount of fees paid to insurance companyUSD $2,257
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $165,478
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $16,854
Amount paid for insurance broker fees2257
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
Insurance broker organization code?3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number444750
Policy instance 12
Insurance contract or identification number444750
Number of Individuals Covered103
Insurance policy start date2021-06-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $6,721
Total amount of fees paid to insurance companyUSD $1,087
Life Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $43,471
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6,721
Amount paid for insurance broker fees1087
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
Insurance broker organization code?3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number444751
Policy instance 11
Insurance contract or identification number444751
Number of Individuals Covered244
Insurance policy start date2021-06-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $6,737
Total amount of fees paid to insurance companyUSD $1,694
Life Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $67,745
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6,737
Amount paid for insurance broker fees1694
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGVTL0BJNW
Policy instance 10
Insurance contract or identification numberGVTL0BJNW
Number of Individuals Covered76
Insurance policy start date2021-01-01
Insurance policy end date2021-05-31
Total amount of commissions paid to insurance brokerUSD $1,677
Total amount of fees paid to insurance companyUSD $3,229
Life Insurance Welfare BenefitYes
Other welfare benefits providedVOLUNTARY LIFE, VOLUNTARY AD&D
Welfare Benefit Premiums Paid to CarrierUSD $20,839
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,677
Amount paid for insurance broker fees3229
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 numberGLUG0BJNW
Policy instance 9
Insurance contract or identification numberGLUG0BJNW
Number of Individuals Covered213
Insurance policy start date2021-01-01
Insurance policy end date2021-05-31
Total amount of commissions paid to insurance brokerUSD $1,936
Total amount of fees paid to insurance companyUSD $3,598
Life Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $24,142
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,936
Amount paid for insurance broker fees3598
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 numberGLTD0BJNW
Policy instance 8
Insurance contract or identification numberGLTD0BJNW
Number of Individuals Covered213
Insurance policy start date2021-01-01
Insurance policy end date2021-05-31
Total amount of commissions paid to insurance brokerUSD $1,786
Total amount of fees paid to insurance companyUSD $3,291
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $22,300
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,786
Amount paid for insurance broker fees3291
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
HEALTH ALLIANCE PLAN (National Association of Insurance Commissioners NAIC id number: 95844 )
Policy contract number10002562
Policy instance 3
Insurance contract or identification number10002562
Number of Individuals Covered66
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $22,303
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $451,274
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $22,303
Insurance broker organization code?3
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract numberETB131007
Policy instance 4
Insurance contract or identification numberETB131007
Number of Individuals Covered209
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $319
Other welfare benefits providedBUSINESS TRAVEL ACCIDENT
Welfare Benefit Premiums Paid to CarrierUSD $2,125
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $319
Insurance broker organization code?3
FOUR EVER LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80985 )
Policy contract number4EL-6656
Policy instance 5
Insurance contract or identification number4EL-6656
Number of Individuals Covered248
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $488
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $3,252
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $488
Insurance broker organization code?3
BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 )
Policy contract number34024
Policy instance 6
Insurance contract or identification number34024
Number of Individuals Covered301
Insurance policy start date2020-01-01
Insurance policy end date2020-05-31
Total amount of commissions paid to insurance brokerUSD $3,761
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $805,435
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,761
Insurance broker organization code?3
PRE-PAID LEGAL SERVICES DBA LEGAL SHIELD (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number202926
Policy instance 7
Insurance contract or identification number202926
Number of Individuals Covered78
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $2,353
Other welfare benefits providedLEGAL
Welfare Benefit Premiums Paid to CarrierUSD $13,155
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,189
Insurance broker organization code?4
STARMOUNT LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68985 )
Policy contract number609220
Policy instance 8
Insurance contract or identification number609220
Number of Individuals Covered177
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $12,190
Total amount of fees paid to insurance companyUSD $2,156
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $121,948
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $12,190
Amount paid for insurance broker fees2156
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLUG0BJNW
Policy instance 10
Insurance contract or identification numberGLUG0BJNW
Number of Individuals Covered209
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $5,996
Total amount of fees paid to insurance companyUSD $1,254
Life Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $59,964
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,996
Amount paid for insurance broker fees1254
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 numberGVTL0BJNW
Policy instance 11
Insurance contract or identification numberGVTL0BJNW
Number of Individuals Covered76
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $5,382
Total amount of fees paid to insurance companyUSD $1,240
Life Insurance Welfare BenefitYes
Other welfare benefits providedVOLUNTARY LIFE, VOLUNTARY AD&D
Welfare Benefit Premiums Paid to CarrierUSD $53,818
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,382
Amount paid for insurance broker fees1240
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
HUMANA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 73288 )
Policy contract number665104
Policy instance 2
Insurance contract or identification number665104
Number of Individuals Covered9
Insurance policy start date2020-01-01
Insurance policy end date2020-03-31
Total amount of commissions paid to insurance brokerUSD $520
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $21,905
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $520
Insurance broker organization code?3
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number97454151001
Policy instance 1
Insurance contract or identification number97454151001
Number of Individuals Covered356
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $2,365
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $21,772
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,365
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLTD0BJNW
Policy instance 9
Insurance contract or identification numberGLTD0BJNW
Number of Individuals Covered209
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $5,484
Total amount of fees paid to insurance companyUSD $1,156
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $54,842
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,484
Amount paid for insurance broker fees1156
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 numberGVTL0BJNW
Policy instance 13
Insurance contract or identification numberGVTL0BJNW
Number of Individuals Covered84
Insurance policy start date2019-06-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $3,330
Life Insurance Welfare BenefitYes
Other welfare benefits providedVOLUNTARY LIFE, VOLUNTARY AD&D
Welfare Benefit Premiums Paid to CarrierUSD $33,302
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,330
Insurance broker organization code?3
PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 )
Policy contract number1071183
Policy instance 1
Insurance contract or identification number1071183
Number of Individuals Covered404
Insurance policy start date2019-01-01
Insurance policy end date2019-05-31
Total amount of commissions paid to insurance brokerUSD $2,903
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $52,886
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,903
Insurance broker organization code?3
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number97454151001
Policy instance 2
Insurance contract or identification number97454151001
Number of Individuals Covered365
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $2,385
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $23,747
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,385
Insurance broker organization code?3
HUMANA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 73288 )
Policy contract number665104
Policy instance 3
Insurance contract or identification number665104
Number of Individuals Covered10
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $2,040
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $90,663
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,040
Insurance broker organization code?3
HEALTH ALLIANCE PLAN (National Association of Insurance Commissioners NAIC id number: 95844 )
Policy contract number10002562
Policy instance 4
Insurance contract or identification number10002562
Number of Individuals Covered62
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $17,850
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $370,435
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $17,850
Insurance broker organization code?3
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract numberETB131007
Policy instance 5
Insurance contract or identification numberETB131007
Number of Individuals Covered229
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $319
Other welfare benefits providedBUSINESS TRAVEL ACCIDENT
Welfare Benefit Premiums Paid to CarrierUSD $2,125
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $319
Insurance broker organization code?3
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number5937695
Policy instance 6
Insurance contract or identification number5937695
Number of Individuals Covered412
Insurance policy start date2019-01-01
Insurance policy end date2019-05-31
Total amount of commissions paid to insurance brokerUSD $8,928
Life Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $441,030
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $8,928
Insurance broker organization code?3
BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 )
Policy contract number34024
Policy instance 8
Insurance contract or identification number34024
Number of Individuals Covered303
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $35,325
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,846,568
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $35,325
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLUG0BJNW
Policy instance 12
Insurance contract or identification numberGLUG0BJNW
Number of Individuals Covered226
Insurance policy start date2019-06-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $3,688
Life Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $36,880
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,688
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLTD0BJNW
Policy instance 11
Insurance contract or identification numberGLTD0BJNW
Number of Individuals Covered226
Insurance policy start date2019-06-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $3,400
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $33,997
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,400
Insurance broker organization code?3
STARMOUNT LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68985 )
Policy contract number609220
Policy instance 10
Insurance contract or identification number609220
Number of Individuals Covered174
Insurance policy start date2019-06-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $6,986
Total amount of fees paid to insurance companyUSD $1,747
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $69,862
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6,986
Amount paid for insurance broker fees1747
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
Insurance broker organization code?3
PRE-PAID LEGAL SERVICES DBA LEGAL SHIELD (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number202926
Policy instance 9
Insurance contract or identification number202926
Number of Individuals Covered328
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $4,069
Other welfare benefits providedLEGAL
Welfare Benefit Premiums Paid to CarrierUSD $13,590
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,192
Insurance broker organization code?4
FOUR EVER LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80985 )
Policy contract number4EL-6656-18
Policy instance 7
Insurance contract or identification number4EL-6656-18
Number of Individuals Covered291
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $513
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $3,423
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $513
Insurance broker organization code?3
PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 )
Policy contract number1071183
Policy instance 1
Insurance contract or identification number1071183
Number of Individuals Covered424
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $5,252
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $131,456
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,252
Insurance broker organization code?3
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number97454151001
Policy instance 2
Insurance contract or identification number97454151001
Number of Individuals Covered376
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $2,411
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $24,084
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,411
Insurance broker organization code?3
HUMANA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 73288 )
Policy contract number665104
Policy instance 3
Insurance contract or identification number665104
Number of Individuals Covered10
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $2,840
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $130,286
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,840
Insurance broker organization code?3
HEALTH ALLIANCE PLAN (National Association of Insurance Commissioners NAIC id number: 95844 )
Policy contract number10002562
Policy instance 4
Insurance contract or identification number10002562
Number of Individuals Covered61
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $19,327
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $410,576
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $19,327
Insurance broker organization code?3
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract numberETB131007
Policy instance 5
Insurance contract or identification numberETB131007
Number of Individuals Covered223
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $319
Other welfare benefits providedBUSINESS TRAVEL ACCIDENT
Welfare Benefit Premiums Paid to CarrierUSD $2,125
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $319
Insurance broker organization code?3
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number5937695
Policy instance 6
Insurance contract or identification number5937695
Number of Individuals Covered851
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $17,406
Total amount of fees paid to insurance companyUSD $237
Life Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $196,992
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $17,406
Amount paid for insurance broker fees237
Additional information about fees paid to insurance brokerSUPPLEMENTAL COMPENSATION NON-MONETARY COMPENSATION
Insurance broker organization code?3
FOUR EVER LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80985 )
Policy contract number4EL-6656-18
Policy instance 7
Insurance contract or identification number4EL-6656-18
Number of Individuals Covered288
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $513
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $3,423
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $513
Insurance broker organization code?3
BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 )
Policy contract number34024
Policy instance 8
Insurance contract or identification number34024
Number of Individuals Covered237
Insurance policy start date2018-04-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $32,910
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,342,459
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $32,910
Insurance broker organization code?3
PRE-PAID LEGAL SERVICES DBA LEGAL SHIELD (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number202926
Policy instance 9
Insurance contract or identification number202926
Number of Individuals Covered311
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $2,599
Other welfare benefits providedLEGAL
Welfare Benefit Premiums Paid to CarrierUSD $6,496
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,430
Insurance broker organization code?4
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number97454151001
Policy instance 2
Insurance contract or identification number97454151001
Number of Individuals Covered361
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $2,694
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $22,769
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,694
Insurance broker organization code?3
Insurance broker nameJ.S. CLARK AGENCY, INC.
HUMANA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 73288 )
Policy contract number665104
Policy instance 3
Insurance contract or identification number665104
Number of Individuals Covered10
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $3,920
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $183,269
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,920
Insurance broker organization code?3
Insurance broker nameJ.S. CLARK AGENCY, INC.
HEALTH ALLIANCE PLAN (National Association of Insurance Commissioners NAIC id number: 95844 )
Policy contract number10002562
Policy instance 4
Insurance contract or identification number10002562
Number of Individuals Covered69
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $22,664
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $422,578
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $22,664
Insurance broker organization code?3
Insurance broker nameJ.S. CLARK AGENCY, INC.
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract numberETB131007
Policy instance 5
Insurance contract or identification numberETB131007
Number of Individuals Covered107
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $350
Other welfare benefits providedBUSINESS TRAVEL ACCIDENT
Welfare Benefit Premiums Paid to CarrierUSD $2,330
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $350
Insurance broker organization code?3
Insurance broker nameJ.S. CLARK AGENCY, INC.
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract numberTM05937695
Policy instance 6
Insurance contract or identification numberTM05937695
Number of Individuals Covered386
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $16,440
Total amount of fees paid to insurance companyUSD $5,246
Life Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $171,699
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $16,440
Amount paid for insurance broker fees5246
Additional information about fees paid to insurance brokerSUPPLEMENTAL COMPENSATION NON-MONETARY COMPENSATION
Insurance broker organization code?3
Insurance broker nameJ.S. CLARK AGENCY, INC.
FOUR EVER LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80985 )
Policy contract number4EL-6656-15
Policy instance 7
Insurance contract or identification number4EL-6656-15
Number of Individuals Covered246
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $849
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $5,659
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $849
Insurance broker organization code?3
Insurance broker nameJ.S. CLARK AGENCY, INC.
PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 )
Policy contract number1071183
Policy instance 1
Insurance contract or identification number1071183
Number of Individuals Covered396
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $4,827
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $118,403
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,827
Insurance broker organization code?3
Insurance broker nameJ.S. CLARK AGENCY, INC.

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