401k Plan data: CORNERSTONE MEDICAL GROUP WELFARE BENEFIT PLAN plan

CORNERSTONE MEDICAL GROUP WELFARE BENEFIT PLAN 401k Plan overview

Plan Name	CORNERSTONE MEDICAL GROUP WELFARE BENEFIT PLAN
Plan identification number	501

CORNERSTONE MEDICAL GROUP WELFARE BENEFIT PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Life insurance Dental Vision Temporary disability (accident and sickness) Long-term disability cover Death benefits (include travel accident but not life insurance)

401k Sponsoring company profile

CORNERSTONE MEDICAL GROUP has sponsored the creation of one or more 401k plans.

Company Name: CORNERSTONE MEDICAL GROUP

Employer identification number (EIN): 812131297

NAIC Classification: 621111
NAIC Description: Offices of Physicians (except Mental Health Specialists)

Form 5500 Filing Information

Submission information for form 5500 for 401k plan CORNERSTONE MEDICAL GROUP WELFARE BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2022-07-01
501 2021-07-01
501 2020-07-01
501 2019-07-01 BRUCE BENDEROFF 2020-12-21
501 2018-07-01 BRUCE BENDEROFF 2019-12-19 BRUCE BENDEROFF 2019-12-19
501 2017-07-01
501 2016-07-01

Plan Statistics for CORNERSTONE MEDICAL GROUP WELFARE BENEFIT PLAN

401k plan membership statisitcs for CORNERSTONE MEDICAL GROUP WELFARE BENEFIT PLAN

Measure Date Value
2022: CORNERSTONE MEDICAL GROUP WELFARE BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year 2022-07-01 1,955
Total number of active participants reported on line 7a of the Form 5500 2022-07-01 1,521
Total of all active and inactive participants 2022-07-01 1,521
Total participants 2022-07-01 1,521
2021: CORNERSTONE MEDICAL GROUP WELFARE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year 2021-07-01 1,896
Total number of active participants reported on line 7a of the Form 5500 2021-07-01 1,955
Total of all active and inactive participants 2021-07-01 1,955
Total participants 2021-07-01 1,955
2020: CORNERSTONE MEDICAL GROUP WELFARE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year 2020-07-01 1,816
Total number of active participants reported on line 7a of the Form 5500 2020-07-01 1,896
Total of all active and inactive participants 2020-07-01 1,896
Total participants 2020-07-01 1,896
2019: CORNERSTONE MEDICAL GROUP WELFARE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year 2019-07-01 820
Total number of active participants reported on line 7a of the Form 5500 2019-07-01 1,816
Number of retired or separated participants receiving benefits 2019-07-01 0
Number of other retired or separated participants entitled to future benefits 2019-07-01 0
Total of all active and inactive participants 2019-07-01 1,816
2018: CORNERSTONE MEDICAL GROUP WELFARE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year 2018-07-01 861
Total number of active participants reported on line 7a of the Form 5500 2018-07-01 820
Number of retired or separated participants receiving benefits 2018-07-01 0
Number of other retired or separated participants entitled to future benefits 2018-07-01 0
Total of all active and inactive participants 2018-07-01 820
2017: CORNERSTONE MEDICAL GROUP WELFARE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year 2017-07-01 751
Total number of active participants reported on line 7a of the Form 5500 2017-07-01 861
Number of retired or separated participants receiving benefits 2017-07-01 0
Number of other retired or separated participants entitled to future benefits 2017-07-01 0
Total of all active and inactive participants 2017-07-01 861
2016: CORNERSTONE MEDICAL GROUP WELFARE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year 2016-07-01 0
Total number of active participants reported on line 7a of the Form 5500 2016-07-01 751
Number of retired or separated participants receiving benefits 2016-07-01 0
Number of other retired or separated participants entitled to future benefits 2016-07-01 0
Total of all active and inactive participants 2016-07-01 751

Measure	Date	Value
2022: CORNERSTONE MEDICAL GROUP WELFARE BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year	2022-07-01	1,955
Total number of active participants reported on line 7a of the Form 5500	2022-07-01	1,521
Total of all active and inactive participants	2022-07-01	1,521
Total participants	2022-07-01	1,521
2021: CORNERSTONE MEDICAL GROUP WELFARE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year	2021-07-01	1,896
Total number of active participants reported on line 7a of the Form 5500	2021-07-01	1,955
Total of all active and inactive participants	2021-07-01	1,955
Total participants	2021-07-01	1,955
2020: CORNERSTONE MEDICAL GROUP WELFARE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year	2020-07-01	1,816
Total number of active participants reported on line 7a of the Form 5500	2020-07-01	1,896
Total of all active and inactive participants	2020-07-01	1,896
Total participants	2020-07-01	1,896
2019: CORNERSTONE MEDICAL GROUP WELFARE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year	2019-07-01	820
Total number of active participants reported on line 7a of the Form 5500	2019-07-01	1,816
Number of retired or separated participants receiving benefits	2019-07-01	0
Number of other retired or separated participants entitled to future benefits	2019-07-01	0
Total of all active and inactive participants	2019-07-01	1,816
2018: CORNERSTONE MEDICAL GROUP WELFARE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year	2018-07-01	861
Total number of active participants reported on line 7a of the Form 5500	2018-07-01	820
Number of retired or separated participants receiving benefits	2018-07-01	0
Number of other retired or separated participants entitled to future benefits	2018-07-01	0
Total of all active and inactive participants	2018-07-01	820
2017: CORNERSTONE MEDICAL GROUP WELFARE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year	2017-07-01	751
Total number of active participants reported on line 7a of the Form 5500	2017-07-01	861
Number of retired or separated participants receiving benefits	2017-07-01	0
Number of other retired or separated participants entitled to future benefits	2017-07-01	0
Total of all active and inactive participants	2017-07-01	861
2016: CORNERSTONE MEDICAL GROUP WELFARE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year	2016-07-01	0
Total number of active participants reported on line 7a of the Form 5500	2016-07-01	751
Number of retired or separated participants receiving benefits	2016-07-01	0
Number of other retired or separated participants entitled to future benefits	2016-07-01	0
Total of all active and inactive participants	2016-07-01	751

Form 5500 Responses for CORNERSTONE MEDICAL GROUP WELFARE BENEFIT PLAN

2022: CORNERSTONE MEDICAL GROUP WELFARE BENEFIT PLAN 2022 form 5500 responses
2022-07-01	Type of plan entity	Single employer plan
2022-07-01	Plan funding arrangement – Insurance	Yes
2022-07-01	Plan benefit arrangement – Insurance	Yes
2021: CORNERSTONE MEDICAL GROUP WELFARE BENEFIT PLAN 2021 form 5500 responses
2021-07-01	Type of plan entity	Single employer plan
2021-07-01	Plan funding arrangement – Insurance	Yes
2021-07-01	Plan benefit arrangement – Insurance	Yes
2020: CORNERSTONE MEDICAL GROUP WELFARE BENEFIT PLAN 2020 form 5500 responses
2020-07-01	Type of plan entity	Single employer plan
2020-07-01	Plan funding arrangement – Insurance	Yes
2020-07-01	Plan benefit arrangement – Insurance	Yes
2019: CORNERSTONE MEDICAL GROUP WELFARE BENEFIT PLAN 2019 form 5500 responses
2019-07-01	Type of plan entity	Single employer plan
2019-07-01	Plan funding arrangement – Insurance	Yes
2019-07-01	Plan benefit arrangement – Insurance	Yes
2018: CORNERSTONE MEDICAL GROUP WELFARE BENEFIT PLAN 2018 form 5500 responses
2018-07-01	Type of plan entity	Single employer plan
2018-07-01	Plan funding arrangement – Insurance	Yes
2018-07-01	Plan benefit arrangement – Insurance	Yes
2017: CORNERSTONE MEDICAL GROUP WELFARE BENEFIT PLAN 2017 form 5500 responses
2017-07-01	Type of plan entity	Single employer plan
2017-07-01	Plan funding arrangement – Insurance	Yes
2017-07-01	Plan benefit arrangement – Insurance	Yes
2016: CORNERSTONE MEDICAL GROUP WELFARE BENEFIT PLAN 2016 form 5500 responses
2016-07-01	Type of plan entity	Single employer plan
2016-07-01	First time form 5500 has been submitted	Yes
2016-07-01	Plan funding arrangement – Insurance	Yes
2016-07-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

BLUE CARE NETWORK OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 95610 )

Policy contract number

283328

Policy instance

Insurance contract or identification number	283328
Number of Individuals Covered	223
Insurance policy start date	2022-07-01
Insurance policy end date	2023-06-30
Total amount of commissions paid to insurance broker	USD $25,646
Total amount of fees paid to insurance company	USD $1,416
Health 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 $25,646
Additional information about fees paid to insurance broker	COMMISSIONS
Insurance broker organization code?	3
Amount paid for insurance broker fees	1416

BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 )

Policy contract number

283328

Policy instance

Insurance contract or identification number	283328
Number of Individuals Covered	313
Insurance policy start date	2022-07-01
Insurance policy end date	2023-06-30
Total amount of commissions paid to insurance broker	USD $62,069
Total amount of fees paid to insurance company	USD $1,572
Health 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 $62,069
Additional information about fees paid to insurance broker	COMMISSIONS
Insurance broker organization code?	3
Amount paid for insurance broker fees	1572

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

912686

Policy instance

Insurance contract or identification number	912686
Number of Individuals Covered	289
Insurance policy start date	2022-07-01
Insurance policy end date	2023-07-01
Total amount of commissions paid to insurance broker	USD $12,792
Total amount of fees paid to insurance company	USD $3,848
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	SHORT-TERM DISABILITY
Welfare Benefit Premiums Paid to Carrier	USD $306,827
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $12,792
Amount paid for insurance broker fees	3848
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

912687

Policy instance

Insurance contract or identification number	912687
Number of Individuals Covered	2
Insurance policy start date	2022-07-01
Insurance policy end date	2023-07-01
Total amount of commissions paid to insurance broker	USD $39
Total amount of fees paid to insurance company	USD $2
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $263
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $39
Amount paid for insurance broker fees	2
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

912689

Policy instance

Insurance contract or identification number	912689
Number of Individuals Covered	115
Insurance policy start date	2022-07-01
Insurance policy end date	2023-07-01
Total amount of commissions paid to insurance broker	USD $9,132
Total amount of fees paid to insurance company	USD $457
Other welfare benefits provided	LIFESTYLE ADD, LIFESTYLE LIFE
Welfare Benefit Premiums Paid to Carrier	USD $60,879
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,132
Amount paid for insurance broker fees	457
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

G000BKCT

Policy instance

Insurance contract or identification number	G000BKCT
Number of Individuals Covered	235
Insurance policy start date	2022-07-01
Insurance policy end date	2023-07-01
Total amount of commissions paid to insurance broker	USD $1,742
Total amount of fees paid to insurance company	USD $1,982
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $27,347
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,742
Amount paid for insurance broker fees	1640
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

G000BKCT

Policy instance

Insurance contract or identification number	G000BKCT
Number of Individuals Covered	29
Insurance policy start date	2022-07-01
Insurance policy end date	2023-07-01
Total amount of commissions paid to insurance broker	USD $570
Total amount of fees paid to insurance company	USD $478
Other welfare benefits provided	CRITICAL ILLNESS VOLUNTARY
Welfare Benefit Premiums Paid to Carrier	USD $5,695
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $570
Amount paid for insurance broker fees	396
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

G000BKCT

Policy instance

Insurance contract or identification number	G000BKCT
Number of Individuals Covered	70
Insurance policy start date	2022-07-01
Insurance policy end date	2023-07-01
Total amount of commissions paid to insurance broker	USD $2,401
Total amount of fees paid to insurance company	USD $1,659
Other welfare benefits provided	ACCIDENT ONLY VOLUNTARY
Welfare Benefit Premiums Paid to Carrier	USD $24,008
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,401
Amount paid for insurance broker fees	1373
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

G000BKCT

Policy instance

Insurance contract or identification number	G000BKCT
Number of Individuals Covered	245
Insurance policy start date	2022-07-01
Insurance policy end date	2023-07-01
Total amount of commissions paid to insurance broker	USD $5,160
Total amount of fees paid to insurance company	USD $8,515
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $199,166
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,160
Amount paid for insurance broker fees	6011
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

912686

Policy instance

Insurance contract or identification number	912686
Number of Individuals Covered	331
Insurance policy start date	2021-07-01
Insurance policy end date	2022-07-01
Total amount of commissions paid to insurance broker	USD $9,437
Total amount of fees paid to insurance company	USD $1,679
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	SHORT-TERM DISABILITY
Welfare Benefit Premiums Paid to Carrier	USD $202,645
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,437
Amount paid for insurance broker fees	1679
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3

BLUE CARE NETWORK OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 95610 )

Policy contract number

283328

Policy instance

Insurance contract or identification number	283328
Number of Individuals Covered	205
Insurance policy start date	2021-07-01
Insurance policy end date	2022-06-30
Total amount of fees paid to insurance company	USD $20,417
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	19241
Additional information about fees paid to insurance broker	COMMISSIONS
Insurance broker organization code?	3

BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 )

Policy contract number

283328

Policy instance

Insurance contract or identification number	283328
Number of Individuals Covered	338
Insurance policy start date	2021-07-01
Insurance policy end date	2022-06-30
Total amount of fees paid to insurance company	USD $48,131
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	46391
Additional information about fees paid to insurance broker	COMMISSIONS
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

G000BKCT

Policy instance

Insurance contract or identification number	G000BKCT
Number of Individuals Covered	66
Insurance policy start date	2021-07-01
Insurance policy end date	2022-07-01
Total amount of commissions paid to insurance broker	USD $2,157
Total amount of fees paid to insurance company	USD $1,607
Other welfare benefits provided	ACCIDENT ONLY VOLUNTARY
Welfare Benefit Premiums Paid to Carrier	USD $21,574
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,157
Insurance broker organization code?	3
Amount paid for insurance broker fees	1330
Additional information about fees paid to insurance broker	OTHER COMPENSATION

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

912687

Policy instance

Insurance contract or identification number	912687
Number of Individuals Covered	2
Insurance policy start date	2021-07-01
Insurance policy end date	2022-07-01
Total amount of commissions paid to insurance broker	USD $123
Total amount of fees paid to insurance company	USD $6
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $728
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $123
Amount paid for insurance broker fees	6
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

912688

Policy instance

Insurance contract or identification number	912688
Number of Individuals Covered	368
Insurance policy start date	2021-07-01
Insurance policy end date	2022-07-01
Total amount of commissions paid to insurance broker	USD $4,093
Total amount of fees paid to insurance company	USD $964
Other welfare benefits provided	FLEX STD
Welfare Benefit Premiums Paid to Carrier	USD $118,563
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,093
Amount paid for insurance broker fees	964
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

912689

Policy instance

Insurance contract or identification number	912689
Number of Individuals Covered	124
Insurance policy start date	2021-07-01
Insurance policy end date	2022-07-01
Total amount of commissions paid to insurance broker	USD $9,892
Total amount of fees paid to insurance company	USD $495
Other welfare benefits provided	LIFESTYLE ADD, LIFESTYLE LIFE
Welfare Benefit Premiums Paid to Carrier	USD $60,730
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,892
Amount paid for insurance broker fees	495
Additional information about fees paid to insurance broker	ADDITONAL COMPENSATION
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

G000BKCT

Policy instance

Insurance contract or identification number	G000BKCT
Number of Individuals Covered	238
Insurance policy start date	2021-07-01
Insurance policy end date	2022-07-01
Total amount of commissions paid to insurance broker	USD $1,720
Total amount of fees paid to insurance company	USD $1,857
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $26,901
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,720
Insurance broker organization code?	3
Amount paid for insurance broker fees	1537
Additional information about fees paid to insurance broker	OTHER COMPENSATION

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

G000BKCT

Policy instance

Insurance contract or identification number	G000BKCT
Number of Individuals Covered	30
Insurance policy start date	2021-07-01
Insurance policy end date	2022-07-01
Total amount of commissions paid to insurance broker	USD $1,174
Total amount of fees paid to insurance company	USD $762
Other welfare benefits provided	CRITICAL ILLNESS VOLUNTARY
Welfare Benefit Premiums Paid to Carrier	USD $11,736
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,174
Insurance broker organization code?	3
Amount paid for insurance broker fees	631
Additional information about fees paid to insurance broker	OTHER COMPENSATION

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

G000BKCT

Policy instance

Insurance contract or identification number	G000BKCT
Number of Individuals Covered	253
Insurance policy start date	2021-07-01
Insurance policy end date	2022-07-01
Total amount of commissions paid to insurance broker	USD $5,074
Total amount of fees paid to insurance company	USD $8,066
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $194,257
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	5694
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3
Commission paid to Insurance Broker	USD $5,074

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

912687

Policy instance

Insurance contract or identification number	912687
Number of Individuals Covered	4
Insurance policy start date	2020-07-01
Insurance policy end date	2021-06-30
Total amount of commissions paid to insurance broker	USD $157
Total amount of fees paid to insurance company	USD $8
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,137
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $157
Amount paid for insurance broker fees	8
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION PAID
Insurance broker organization code?	3

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

912688

Policy instance

Insurance contract or identification number	912688
Number of Individuals Covered	360
Insurance policy start date	2020-07-01
Insurance policy end date	2021-06-30
Total amount of commissions paid to insurance broker	USD $4,087
Total amount of fees paid to insurance company	USD $1,077
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $137,454
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,087
Amount paid for insurance broker fees	1077
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GUDS0BKCT

Policy instance

Insurance contract or identification number	GUDS0BKCT
Number of Individuals Covered	229
Insurance policy start date	2020-07-01
Insurance policy end date	2021-06-30
Total amount of commissions paid to insurance broker	USD $4,913
Total amount of fees paid to insurance company	USD $6,885
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $185,017
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,913
Amount paid for insurance broker fees	4860
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GUDH0BKCT

Policy instance

Insurance contract or identification number	GUDH0BKCT
Number of Individuals Covered	73
Insurance policy start date	2020-07-01
Insurance policy end date	2021-06-30
Total amount of commissions paid to insurance broker	USD $2,188
Total amount of fees paid to insurance company	USD $1,400
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $21,881
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,188
Amount paid for insurance broker fees	1159
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GUDE0BKCT

Policy instance

Insurance contract or identification number	GUDE0BKCT
Number of Individuals Covered	38
Insurance policy start date	2020-07-01
Insurance policy end date	2021-06-30
Total amount of commissions paid to insurance broker	USD $884
Total amount of fees paid to insurance company	USD $625
Other welfare benefits provided	CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $8,836
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $884
Amount paid for insurance broker fees	517
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GLLV0BKCT

Policy instance

Insurance contract or identification number	GLLV0BKCT
Number of Individuals Covered	218
Insurance policy start date	2020-07-01
Insurance policy end date	2021-06-30
Total amount of commissions paid to insurance broker	USD $1,595
Total amount of fees paid to insurance company	USD $1,604
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $24,408
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,595
Amount paid for insurance broker fees	1327
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 )

Policy contract number

283328

Policy instance

Insurance contract or identification number	283328
Number of Individuals Covered	345
Insurance policy start date	2020-07-01
Insurance policy end date	2021-06-30
Total amount of commissions paid to insurance broker	USD $38,710
Total amount of fees paid to insurance company	USD $1,758
Health 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 $38,710
Insurance broker organization code?	3
Amount paid for insurance broker fees	1758

BLUE CARE NETWORK OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 95610 )

Policy contract number

283328

Policy instance

Insurance contract or identification number	283328
Number of Individuals Covered	190
Insurance policy start date	2020-07-01
Insurance policy end date	2021-06-30
Total amount of commissions paid to insurance broker	USD $19,253
Total amount of fees paid to insurance company	USD $1,014
Health 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 $19,253
Insurance broker organization code?	3
Amount paid for insurance broker fees	1014

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

912689

Policy instance

Insurance contract or identification number	912689
Number of Individuals Covered	103
Insurance policy start date	2020-07-01
Insurance policy end date	2021-06-30
Total amount of commissions paid to insurance broker	USD $7,504
Total amount of fees paid to insurance company	USD $375
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $54,861
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,504
Amount paid for insurance broker fees	375
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION PAID
Insurance broker organization code?	3

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

912686

Policy instance

Insurance contract or identification number	912686
Number of Individuals Covered	336
Insurance policy start date	2020-07-01
Insurance policy end date	2021-06-30
Total amount of commissions paid to insurance broker	USD $9,049
Total amount of fees paid to insurance company	USD $1,628
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $214,418
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,049
Amount paid for insurance broker fees	1628
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION PAID
Insurance broker organization code?	3

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

912688

Policy instance

Insurance contract or identification number	912688
Number of Individuals Covered	355
Insurance policy start date	2019-07-01
Insurance policy end date	2020-06-30
Total amount of commissions paid to insurance broker	USD $4,171
Total amount of fees paid to insurance company	USD $2,085
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $104,261
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,171
Amount paid for insurance broker fees	2085
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION PAID
Insurance broker organization code?	3

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

912687

Policy instance

Insurance contract or identification number	912687
Number of Individuals Covered	5
Insurance policy start date	2019-07-01
Insurance policy end date	2020-06-30
Total amount of commissions paid to insurance broker	USD $393
Total amount of fees paid to insurance company	USD $24
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,285
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
Amount paid for insurance broker fees	24
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION PAID
Insurance broker organization code?	3

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

912686

Policy instance

Insurance contract or identification number	912686
Number of Individuals Covered	321
Insurance policy start date	2019-07-01
Insurance policy end date	2020-06-30
Total amount of commissions paid to insurance broker	USD $9,268
Total amount of fees paid to insurance company	USD $3,837
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $207,818
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,268
Amount paid for insurance broker fees	3837
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION PAID
Insurance broker organization code?	3

BLUE CARE NETWORK OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 95610 )

Policy contract number

283328

Policy instance

Insurance contract or identification number	283328
Number of Individuals Covered	183
Insurance policy start date	2019-07-01
Insurance policy end date	2020-06-30
Total amount of commissions paid to insurance broker	USD $17,744
Total amount of fees paid to insurance company	USD $955
Health 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 $17,744
Insurance broker organization code?	3
Amount paid for insurance broker fees	955

BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 )

Policy contract number

283328

Policy instance

Insurance contract or identification number	283328
Number of Individuals Covered	322
Insurance policy start date	2019-07-01
Insurance policy end date	2020-06-30
Total amount of commissions paid to insurance broker	USD $36,948
Total amount of fees paid to insurance company	USD $1,805
Health 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 $36,948
Insurance broker organization code?	3
Amount paid for insurance broker fees	1805

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

912689

Policy instance

Insurance contract or identification number	912689
Number of Individuals Covered	99
Insurance policy start date	2019-07-01
Insurance policy end date	2020-06-30
Total amount of commissions paid to insurance broker	USD $9,383
Total amount of fees paid to insurance company	USD $1,162
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $61,604
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,383
Amount paid for insurance broker fees	1162
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION PAID
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GLLV0BKCT

Policy instance

Insurance contract or identification number	GLLV0BKCT
Number of Individuals Covered	210
Insurance policy start date	2019-07-01
Insurance policy end date	2020-06-30
Total amount of commissions paid to insurance broker	USD $1,586
Total amount of fees paid to insurance company	USD $507
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $24,229
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,586
Amount paid for insurance broker fees	358
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GUDE0BCKT

Policy instance

Insurance contract or identification number	GUDE0BCKT
Number of Individuals Covered	38
Insurance policy start date	2019-07-01
Insurance policy end date	2020-06-30
Total amount of commissions paid to insurance broker	USD $996
Total amount of fees paid to insurance company	USD $208
Other welfare benefits provided	CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $9,962
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $996
Amount paid for insurance broker fees	147
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GUDH0BKCT

Policy instance

Insurance contract or identification number	GUDH0BKCT
Number of Individuals Covered	62
Insurance policy start date	2019-07-01
Insurance policy end date	2020-06-30
Total amount of commissions paid to insurance broker	USD $2,065
Total amount of fees paid to insurance company	USD $438
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $20,654
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,065
Amount paid for insurance broker fees	309
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GUDS0BKCT

Policy instance

Insurance contract or identification number	GUDS0BKCT
Number of Individuals Covered	221
Insurance policy start date	2019-07-01
Insurance policy end date	2020-06-30
Total amount of commissions paid to insurance broker	USD $4,798
Total amount of fees paid to insurance company	USD $1,911
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $178,468
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,798
Amount paid for insurance broker fees	1349
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )

Policy contract number

00528015

Policy instance

Insurance contract or identification number	00528015
Number of Individuals Covered	321
Insurance policy start date	2018-07-01
Insurance policy end date	2019-06-30
Total amount of commissions paid to insurance broker	USD $43,207
Total amount of fees paid to insurance company	USD $8,321
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $803,722
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $35,316
Amount paid for insurance broker fees	8321
Insurance broker organization code?	3

BLUE CARE NETWORK OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 95610 )

Policy contract number

283328

Policy instance

Insurance contract or identification number	283328
Number of Individuals Covered	158
Insurance policy start date	2018-07-01
Insurance policy end date	2019-06-30
Total amount of commissions paid to insurance broker	USD $10,837
Total amount of fees paid to insurance company	USD $27
Health 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 $7,230
Insurance broker organization code?	3
Amount paid for insurance broker fees	27

BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 )

Policy contract number

283328

Policy instance

Insurance contract or identification number	283328
Number of Individuals Covered	341
Insurance policy start date	2018-07-01
Insurance policy end date	2019-06-30
Total amount of commissions paid to insurance broker	USD $24,143
Total amount of fees paid to insurance company	USD $63
Health 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 $18,683
Insurance broker organization code?	3
Amount paid for insurance broker fees	63

THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )

Policy contract number

00530100

Policy instance

Insurance contract or identification number	00530100
Number of Individuals Covered	77
Insurance policy start date	2017-07-01
Insurance policy end date	2018-06-30
Total amount of commissions paid to insurance broker	USD $8,108
Total amount of fees paid to insurance company	USD $3,227
Other welfare benefits provided	CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $45,334
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,108
Amount paid for insurance broker fees	3227
Insurance broker organization code?	3
Insurance broker name	LAYNE FINANCIAL INC

THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )

Policy contract number

00528015

Policy instance

Insurance contract or identification number	00528015
Number of Individuals Covered	309
Insurance policy start date	2017-07-01
Insurance policy end date	2018-06-30
Total amount of commissions paid to insurance broker	USD $39,109
Total amount of fees paid to insurance company	USD $5,220
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $749,866
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $25,334
Amount paid for insurance broker fees	5220
Insurance broker name	COMPASS BENEFIT GROUP LTD

BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 )

Policy contract number

283328

Policy instance

Insurance contract or identification number	283328
Number of Individuals Covered	365
Insurance policy start date	2017-07-01
Insurance policy end date	2018-06-30
Total amount of commissions paid to insurance broker	USD $26,419
Total amount of fees paid to insurance company	USD $1,848
Health 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 $21,192
Amount paid for insurance broker fees	1848
Insurance broker organization code?	3
Insurance broker name	JOHN L DALY

BLUE CARE NETWORK OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 95610 )

Policy contract number

283328

Policy instance

Insurance contract or identification number	283328
Number of Individuals Covered	110
Insurance policy start date	2017-07-01
Insurance policy end date	2018-06-30
Total amount of commissions paid to insurance broker	USD $8,037
Total amount of fees paid to insurance company	USD $495
Health 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 $6,851
Amount paid for insurance broker fees	495
Insurance broker organization code?	3
Insurance broker name	JOHN L DALY

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Company Name:	CORNERSTONE MEDICAL GROUP
Employer identification number (EIN):	812131297
NAIC Classification:	621111
NAIC Description:	Offices of Physicians (except Mental Health Specialists)