REX SIGNATURE SERVICES, LLC has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan REX MOORE EMPLOYEE BENEFIT PLAN
| Measure | Date | Value |
|---|
| 2023 : REX MOORE EMPLOYEE BENEFIT PLAN 2023 401k financial data |
|---|
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2023-04-30 | $760,800 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2023-04-30 | $600,400 |
| Total income from all sources (including contributions) | 2023-04-30 | $6,986,030 |
| Total of all expenses incurred | 2023-04-30 | $6,934,202 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2023-04-30 | $6,504,164 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2023-04-30 | $6,986,030 |
| Value of total assets at end of year | 2023-04-30 | $2,375,503 |
| Value of total assets at beginning of year | 2023-04-30 | $2,163,275 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2023-04-30 | $430,038 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2023-04-30 | No |
| Was this plan covered by a fidelity bond | 2023-04-30 | Yes |
| Value of fidelity bond cover | 2023-04-30 | $2,000,000 |
| Were there any nonexempt tranactions with any party-in-interest | 2023-04-30 | No |
| Contributions received from participants | 2023-04-30 | $1,384,780 |
| Participant contributions at end of year | 2023-04-30 | $89,496 |
| Participant contributions at beginning of year | 2023-04-30 | $91,093 |
| Value of other receiveables (less allowance for doubtful accounts) at end of year | 2023-04-30 | $308,538 |
| Value of other receiveables (less allowance for doubtful accounts) at beginning of year | 2023-04-30 | $382,837 |
| Administrative expenses (other) incurred | 2023-04-30 | $118,676 |
| Total non interest bearing cash at end of year | 2023-04-30 | $1,560,293 |
| Total non interest bearing cash at beginning of year | 2023-04-30 | $1,436,496 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2023-04-30 | No |
| Value of net income/loss | 2023-04-30 | $51,828 |
| Value of net assets at end of year (total assets less liabilities) | 2023-04-30 | $1,614,703 |
| Value of net assets at beginning of year (total assets less liabilities) | 2023-04-30 | $1,562,875 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2023-04-30 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2023-04-30 | No |
| Were any leases to which the plan was party in default or uncollectible | 2023-04-30 | No |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2023-04-30 | $1,383,537 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2023-04-30 | No |
| Was there a failure to transmit to the plan any participant contributions | 2023-04-30 | Yes |
| Has the plan failed to provide any benefit when due under the plan | 2023-04-30 | No |
| Contributions received in cash from employer | 2023-04-30 | $5,601,250 |
| Employer contributions (assets) at end of year | 2023-04-30 | $417,176 |
| Employer contributions (assets) at beginning of year | 2023-04-30 | $252,849 |
| Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers | 2023-04-30 | $5,120,627 |
| Contract administrator fees | 2023-04-30 | $311,362 |
| Liabilities. Value of benefit claims payable at end of year | 2023-04-30 | $760,800 |
| Liabilities. Value of benefit claims payable at beginning of year | 2023-04-30 | $600,400 |
| Did the plan have assets held for investment | 2023-04-30 | No |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2023-04-30 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2023-04-30 | No |
| Opinion of an independent qualified public accountant for this plan | 2023-04-30 | Unqualified |
| Accountancy firm name | 2023-04-30 | MOSS ADAMS LLP |
| Accountancy firm EIN | 2023-04-30 | 910189318 |
| 2022 : REX MOORE EMPLOYEE BENEFIT PLAN 2022 401k financial data |
|---|
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2022-04-30 | $600,400 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2022-04-30 | $592,800 |
| Total income from all sources (including contributions) | 2022-04-30 | $5,653,674 |
| Total of all expenses incurred | 2022-04-30 | $5,737,645 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2022-04-30 | $5,244,888 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2022-04-30 | $5,653,674 |
| Value of total assets at end of year | 2022-04-30 | $2,163,275 |
| Value of total assets at beginning of year | 2022-04-30 | $2,239,646 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2022-04-30 | $492,757 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2022-04-30 | No |
| Was this plan covered by a fidelity bond | 2022-04-30 | Yes |
| Value of fidelity bond cover | 2022-04-30 | $2,000,000 |
| Were there any nonexempt tranactions with any party-in-interest | 2022-04-30 | No |
| Contributions received from participants | 2022-04-30 | $1,296,708 |
| Participant contributions at end of year | 2022-04-30 | $91,093 |
| Participant contributions at beginning of year | 2022-04-30 | $52,762 |
| Value of other receiveables (less allowance for doubtful accounts) at end of year | 2022-04-30 | $382,837 |
| Value of other receiveables (less allowance for doubtful accounts) at beginning of year | 2022-04-30 | $568,323 |
| Administrative expenses (other) incurred | 2022-04-30 | $113,394 |
| Total non interest bearing cash at end of year | 2022-04-30 | $1,436,496 |
| Total non interest bearing cash at beginning of year | 2022-04-30 | $1,390,893 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2022-04-30 | No |
| Value of net income/loss | 2022-04-30 | $-83,971 |
| Value of net assets at end of year (total assets less liabilities) | 2022-04-30 | $1,562,875 |
| Value of net assets at beginning of year (total assets less liabilities) | 2022-04-30 | $1,646,846 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2022-04-30 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2022-04-30 | No |
| Were any leases to which the plan was party in default or uncollectible | 2022-04-30 | No |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2022-04-30 | $1,241,936 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2022-04-30 | No |
| Was there a failure to transmit to the plan any participant contributions | 2022-04-30 | No |
| Has the plan failed to provide any benefit when due under the plan | 2022-04-30 | No |
| Contributions received in cash from employer | 2022-04-30 | $4,356,966 |
| Employer contributions (assets) at end of year | 2022-04-30 | $252,849 |
| Employer contributions (assets) at beginning of year | 2022-04-30 | $227,668 |
| Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers | 2022-04-30 | $4,002,952 |
| Contract administrator fees | 2022-04-30 | $379,363 |
| Liabilities. Value of benefit claims payable at end of year | 2022-04-30 | $600,400 |
| Liabilities. Value of benefit claims payable at beginning of year | 2022-04-30 | $592,800 |
| Did the plan have assets held for investment | 2022-04-30 | No |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2022-04-30 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2022-04-30 | No |
| Opinion of an independent qualified public accountant for this plan | 2022-04-30 | Unqualified |
| Accountancy firm name | 2022-04-30 | MOSS ADAMS LLP |
| Accountancy firm EIN | 2022-04-30 | 910189318 |
| 2021 : REX MOORE EMPLOYEE BENEFIT PLAN 2021 401k financial data |
|---|
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2021-04-30 | $592,800 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2021-04-30 | $543,633 |
| Total income from all sources (including contributions) | 2021-04-30 | $5,636,287 |
| Total of all expenses incurred | 2021-04-30 | $5,594,285 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2021-04-30 | $5,204,619 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2021-04-30 | $5,636,287 |
| Value of total assets at end of year | 2021-04-30 | $2,239,646 |
| Value of total assets at beginning of year | 2021-04-30 | $2,148,477 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2021-04-30 | $389,666 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2021-04-30 | No |
| Was this plan covered by a fidelity bond | 2021-04-30 | Yes |
| Value of fidelity bond cover | 2021-04-30 | $2,000,000 |
| Were there any nonexempt tranactions with any party-in-interest | 2021-04-30 | No |
| Contributions received from participants | 2021-04-30 | $942,755 |
| Participant contributions at end of year | 2021-04-30 | $52,762 |
| Value of other receiveables (less allowance for doubtful accounts) at end of year | 2021-04-30 | $568,323 |
| Value of other receiveables (less allowance for doubtful accounts) at beginning of year | 2021-04-30 | $31,975 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year | 2021-04-30 | $18,433 |
| Administrative expenses (other) incurred | 2021-04-30 | $109,088 |
| Total non interest bearing cash at end of year | 2021-04-30 | $1,390,893 |
| Total non interest bearing cash at beginning of year | 2021-04-30 | $2,116,502 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2021-04-30 | No |
| Value of net income/loss | 2021-04-30 | $42,002 |
| Value of net assets at end of year (total assets less liabilities) | 2021-04-30 | $1,646,846 |
| Value of net assets at beginning of year (total assets less liabilities) | 2021-04-30 | $1,604,844 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2021-04-30 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2021-04-30 | No |
| Were any leases to which the plan was party in default or uncollectible | 2021-04-30 | No |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2021-04-30 | $977,044 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2021-04-30 | No |
| Was there a failure to transmit to the plan any participant contributions | 2021-04-30 | No |
| Has the plan failed to provide any benefit when due under the plan | 2021-04-30 | No |
| Contributions received in cash from employer | 2021-04-30 | $4,693,532 |
| Employer contributions (assets) at end of year | 2021-04-30 | $227,668 |
| Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers | 2021-04-30 | $4,227,575 |
| Contract administrator fees | 2021-04-30 | $280,578 |
| Liabilities. Value of benefit claims payable at end of year | 2021-04-30 | $592,800 |
| Liabilities. Value of benefit claims payable at beginning of year | 2021-04-30 | $525,200 |
| Did the plan have assets held for investment | 2021-04-30 | No |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2021-04-30 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2021-04-30 | No |
| Opinion of an independent qualified public accountant for this plan | 2021-04-30 | Unqualified |
| Accountancy firm name | 2021-04-30 | MOSS ADAMS LLP |
| Accountancy firm EIN | 2021-04-30 | 910189318 |
| 2020 : REX MOORE EMPLOYEE BENEFIT PLAN 2020 401k financial data |
|---|
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2020-04-30 | $543,633 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2020-04-30 | $596,601 |
| Total income from all sources (including contributions) | 2020-04-30 | $5,716,312 |
| Total of all expenses incurred | 2020-04-30 | $4,846,578 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2020-04-30 | $4,460,272 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2020-04-30 | $5,716,312 |
| Value of total assets at end of year | 2020-04-30 | $2,148,477 |
| Value of total assets at beginning of year | 2020-04-30 | $1,331,711 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2020-04-30 | $386,306 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2020-04-30 | No |
| Administrative expenses professional fees incurred | 2020-04-30 | $22,345 |
| Was this plan covered by a fidelity bond | 2020-04-30 | Yes |
| Value of fidelity bond cover | 2020-04-30 | $2,000,000 |
| Were there any nonexempt tranactions with any party-in-interest | 2020-04-30 | No |
| Contributions received from participants | 2020-04-30 | $940,895 |
| Participant contributions at beginning of year | 2020-04-30 | $53,776 |
| Value of other receiveables (less allowance for doubtful accounts) at end of year | 2020-04-30 | $31,975 |
| Value of other receiveables (less allowance for doubtful accounts) at beginning of year | 2020-04-30 | $18,220 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year | 2020-04-30 | $18,433 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year | 2020-04-30 | $851 |
| Administrative expenses (other) incurred | 2020-04-30 | $109,157 |
| Liabilities. Value of operating payables at beginning of year | 2020-04-30 | $12,750 |
| Total non interest bearing cash at end of year | 2020-04-30 | $2,116,502 |
| Total non interest bearing cash at beginning of year | 2020-04-30 | $1,259,715 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2020-04-30 | No |
| Value of net income/loss | 2020-04-30 | $869,734 |
| Value of net assets at end of year (total assets less liabilities) | 2020-04-30 | $1,604,844 |
| Value of net assets at beginning of year (total assets less liabilities) | 2020-04-30 | $735,110 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2020-04-30 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2020-04-30 | No |
| Were any leases to which the plan was party in default or uncollectible | 2020-04-30 | No |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2020-04-30 | $1,027,687 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2020-04-30 | No |
| Was there a failure to transmit to the plan any participant contributions | 2020-04-30 | No |
| Has the plan failed to provide any benefit when due under the plan | 2020-04-30 | No |
| Contributions received in cash from employer | 2020-04-30 | $4,775,417 |
| Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers | 2020-04-30 | $3,432,585 |
| Contract administrator fees | 2020-04-30 | $254,804 |
| Liabilities. Value of benefit claims payable at end of year | 2020-04-30 | $525,200 |
| Liabilities. Value of benefit claims payable at beginning of year | 2020-04-30 | $583,000 |
| Did the plan have assets held for investment | 2020-04-30 | No |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2020-04-30 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2020-04-30 | No |
| Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d) | 2020-04-30 | No |
| Opinion of an independent qualified public accountant for this plan | 2020-04-30 | Unqualified |
| Accountancy firm name | 2020-04-30 | MOSS ADAMS LLP |
| Accountancy firm EIN | 2020-04-30 | 910189318 |
| 2018 : REX MOORE EMPLOYEE BENEFIT PLAN 2018 401k financial data |
|---|
| Total unrealized appreciation/depreciation of assets | 2018-04-30 | $0 |
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2018-04-30 | $545,719 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2018-04-30 | $578,502 |
| Total income from all sources (including contributions) | 2018-04-30 | $5,307,504 |
| Total loss/gain on sale of assets | 2018-04-30 | $0 |
| Total of all expenses incurred | 2018-04-30 | $4,540,843 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2018-04-30 | $4,094,906 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2018-04-30 | $5,307,504 |
| Value of total assets at end of year | 2018-04-30 | $1,384,759 |
| Value of total assets at beginning of year | 2018-04-30 | $650,881 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2018-04-30 | $445,937 |
| Total interest from all sources | 2018-04-30 | $0 |
| Total dividends received (eg from common stock, registered investment company shares) | 2018-04-30 | $0 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2018-04-30 | No |
| Was this plan covered by a fidelity bond | 2018-04-30 | Yes |
| Value of fidelity bond cover | 2018-04-30 | $2,000,000 |
| If this is an individual account plan, was there a blackout period | 2018-04-30 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2018-04-30 | No |
| Contributions received from participants | 2018-04-30 | $860,867 |
| Participant contributions at end of year | 2018-04-30 | $14,816 |
| Participant contributions at beginning of year | 2018-04-30 | $16,744 |
| Expenses. Other payments made (not to insurance carriers or or participants/beneficiaries) | 2018-04-30 | $95,167 |
| Value of other receiveables (less allowance for doubtful accounts) at end of year | 2018-04-30 | $5,077 |
| Value of other receiveables (less allowance for doubtful accounts) at beginning of year | 2018-04-30 | $77,825 |
| Administrative expenses (other) incurred | 2018-04-30 | $126,165 |
| Liabilities. Value of operating payables at end of year | 2018-04-30 | $46,111 |
| Liabilities. Value of operating payables at beginning of year | 2018-04-30 | $35,612 |
| Total non interest bearing cash at end of year | 2018-04-30 | $1,290,955 |
| Total non interest bearing cash at beginning of year | 2018-04-30 | $434,272 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2018-04-30 | No |
| Value of net income/loss | 2018-04-30 | $766,661 |
| Value of net assets at end of year (total assets less liabilities) | 2018-04-30 | $839,040 |
| Value of net assets at beginning of year (total assets less liabilities) | 2018-04-30 | $72,379 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2018-04-30 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2018-04-30 | No |
| Were any leases to which the plan was party in default or uncollectible | 2018-04-30 | No |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2018-04-30 | $884,482 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2018-04-30 | No |
| Was there a failure to transmit to the plan any participant contributions | 2018-04-30 | No |
| Has the plan failed to provide any benefit when due under the plan | 2018-04-30 | No |
| Contributions received in cash from employer | 2018-04-30 | $4,446,637 |
| Employer contributions (assets) at end of year | 2018-04-30 | $73,911 |
| Employer contributions (assets) at beginning of year | 2018-04-30 | $122,040 |
| Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers | 2018-04-30 | $3,115,257 |
| Contract administrator fees | 2018-04-30 | $319,772 |
| Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-3 | 2018-04-30 | No |
| Liabilities. Value of benefit claims payable at end of year | 2018-04-30 | $499,608 |
| Liabilities. Value of benefit claims payable at beginning of year | 2018-04-30 | $542,890 |
| Did the plan have assets held for investment | 2018-04-30 | No |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2018-04-30 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2018-04-30 | No |
| Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d) | 2018-04-30 | No |
| Opinion of an independent qualified public accountant for this plan | 2018-04-30 | Unqualified |
| Accountancy firm name | 2018-04-30 | CLIFTONLARSONALLEN LLP |
| Accountancy firm EIN | 2018-04-30 | 410746749 |
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUG0APGE |
| Policy instance | 2 |
| Insurance contract or identification number | GUG0APGE | | Number of Individuals Covered | 27 | | Insurance policy start date | 2022-05-01 | | Insurance policy end date | 2023-04-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $111 | | Other welfare benefits provided | VOLUNTARY ST DISABILITY | | Welfare Benefit Premiums Paid to Carrier | USD $3,434 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 111 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| TRANSAMERICA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 86231 ) |
| Policy contract number | ER00024327 |
| Policy instance | 6 |
| Insurance contract or identification number | ER00024327 | | Number of Individuals Covered | 77 | | Insurance policy start date | 2022-05-01 | | Insurance policy end date | 2023-04-30 | | Total amount of commissions paid to insurance broker | USD $3,008 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | VOLUNTARY HOSPITAL | | Welfare Benefit Premiums Paid to Carrier | USD $15,322 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,789 | | Insurance broker organization code? | 3 |
|
| TRANSAMERICA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 86231 ) |
| Policy contract number | ER00024327 |
| Policy instance | 5 |
| Insurance contract or identification number | ER00024327 | | Number of Individuals Covered | 131 | | Insurance policy start date | 2022-05-01 | | Insurance policy end date | 2023-04-30 | | Total amount of commissions paid to insurance broker | USD $5,112 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | VOLUNTARY ACCIDENT | | Welfare Benefit Premiums Paid to Carrier | USD $21,445 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,771 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG0APGE |
| Policy instance | 4 |
| Insurance contract or identification number | GLUG0APGE | | Number of Individuals Covered | 623 | | Insurance policy start date | 2022-05-01 | | Insurance policy end date | 2023-04-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $552 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $16,285 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 552 | | 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 | GVTL0APGE |
| Policy instance | 3 |
| Insurance contract or identification number | GVTL0APGE | | Number of Individuals Covered | 153 | | Insurance policy start date | 2022-05-01 | | Insurance policy end date | 2023-04-30 | | Total amount of commissions paid to insurance broker | USD $5,588 | | Total amount of fees paid to insurance company | USD $1,713 | | Other welfare benefits provided | VOLUNTARY LIFE AND AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $50,602 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,588 | | Amount paid for insurance broker fees | 1713 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| SYMETRA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68608 ) |
| Policy contract number | 16-015751-000 |
| Policy instance | 7 |
| Insurance contract or identification number | 16-015751-000 | | Number of Individuals Covered | 379 | | Insurance policy start date | 2022-05-01 | | Insurance policy end date | 2023-04-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $50,728 | | Welfare Benefit Premiums Paid to Carrier | USD $1,118,310 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 50728 | | Additional information about fees paid to insurance broker | GROUP ADMINISTRATIVE SUPPORT FEE | | Insurance broker organization code? | 3 |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 30056785 |
| Policy instance | 1 |
| Insurance contract or identification number | 30056785 | | Number of Individuals Covered | 299 | | Insurance policy start date | 2022-05-01 | | Insurance policy end date | 2023-04-30 | | Total amount of commissions paid to insurance broker | USD $2,020 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $56,220 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,020 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUG0APGE |
| Policy instance | 2 |
| Insurance contract or identification number | GUG0APGE | | Number of Individuals Covered | 19 | | Insurance policy start date | 2021-05-01 | | Insurance policy end date | 2022-04-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $123 | | Other welfare benefits provided | VOLUNTARY ST DISABILITY | | Welfare Benefit Premiums Paid to Carrier | USD $3,196 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 123 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 30056785 |
| Policy instance | 1 |
| Insurance contract or identification number | 30056785 | | Number of Individuals Covered | 281 | | Insurance policy start date | 2021-05-01 | | Insurance policy end date | 2022-04-30 | | Total amount of commissions paid to insurance broker | USD $1,941 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $54,736 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,941 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GVTL0APGE |
| Policy instance | 3 |
| Insurance contract or identification number | GVTL0APGE | | Number of Individuals Covered | 129 | | Insurance policy start date | 2021-05-01 | | Insurance policy end date | 2022-04-30 | | Total amount of commissions paid to insurance broker | USD $6,283 | | Total amount of fees paid to insurance company | USD $1,769 | | Other welfare benefits provided | VOLUNTARY LIFE AND AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $49,809 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,283 | | Amount paid for insurance broker fees | 1769 | | 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 | GLUG0APGE |
| Policy instance | 4 |
| Insurance contract or identification number | GLUG0APGE | | Number of Individuals Covered | 523 | | Insurance policy start date | 2021-05-01 | | Insurance policy end date | 2022-04-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $544 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $15,819 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 544 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| TRANSAMERICA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 86231 ) |
| Policy contract number | ER00024327 |
| Policy instance | 5 |
| Insurance contract or identification number | ER00024327 | | Number of Individuals Covered | 114 | | Insurance policy start date | 2021-05-01 | | Insurance policy end date | 2022-04-30 | | Total amount of commissions paid to insurance broker | USD $4,196 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | VOLUNTARY ACCIDENT | | Welfare Benefit Premiums Paid to Carrier | USD $22,168 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,542 | | Insurance broker organization code? | 3 |
|
| TRANSAMERICA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 86231 ) |
| Policy contract number | ER00024327 |
| Policy instance | 6 |
| Insurance contract or identification number | ER00024327 | | Number of Individuals Covered | 56 | | Insurance policy start date | 2021-05-01 | | Insurance policy end date | 2022-04-30 | | Total amount of commissions paid to insurance broker | USD $2,185 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | VOLUNTARY HOSPITAL | | Welfare Benefit Premiums Paid to Carrier | USD $14,323 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,907 | | Insurance broker organization code? | 3 |
|
| RELIASTAR LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 67105 ) |
| Policy contract number | EXRK 71567-1 |
| Policy instance | 7 |
| Insurance contract or identification number | EXRK 71567-1 | | Number of Individuals Covered | 355 | | Insurance policy start date | 2021-05-01 | | Insurance policy end date | 2022-04-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $47,066 | | Welfare Benefit Premiums Paid to Carrier | USD $940,853 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 47066 | | Additional information about fees paid to insurance broker | SERVICE FEE | | Insurance broker organization code? | 3 |
|
| HCC LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 92711 ) |
| Policy contract number | HCCLOT40784 |
| Policy instance | 8 |
| Insurance contract or identification number | HCCLOT40784 | | Number of Individuals Covered | 371 | | Insurance policy start date | 2021-05-01 | | Insurance policy end date | 2022-04-30 | | Total amount of commissions paid to insurance broker | USD $3,059 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | ORGAN TRANSPLANT | | Welfare Benefit Premiums Paid to Carrier | USD $30,594 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,059 | | Insurance broker organization code? | 3 |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 30007652 |
| Policy instance | 1 |
| Insurance contract or identification number | 30007652 | | Number of Individuals Covered | 319 | | Insurance policy start date | 2020-05-01 | | Insurance policy end date | 2021-04-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 30056785 |
| Policy instance | 2 |
| Insurance contract or identification number | 30056785 | | Number of Individuals Covered | 288 | | Insurance policy start date | 2020-05-01 | | Insurance policy end date | 2021-04-30 | | Total amount of commissions paid to insurance broker | USD $1,867 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $54,665 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,867 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUG0APGE |
| Policy instance | 3 |
| Insurance contract or identification number | GUG0APGE | | Number of Individuals Covered | 25 | | Insurance policy start date | 2020-05-01 | | Insurance policy end date | 2021-04-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $179 | | Other welfare benefits provided | VOLUNTARY ST DISABILITY | | Welfare Benefit Premiums Paid to Carrier | USD $3,934 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 179 | | 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 | GVTL0APGE |
| Policy instance | 4 |
| Insurance contract or identification number | GVTL0APGE | | Number of Individuals Covered | 143 | | Insurance policy start date | 2020-05-01 | | Insurance policy end date | 2021-04-30 | | Total amount of commissions paid to insurance broker | USD $6,264 | | Total amount of fees paid to insurance company | USD $2,253 | | Other welfare benefits provided | VOLUNTARY LIFE AND AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $49,605 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,264 | | Amount paid for insurance broker fees | 2253 | | 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 | GLUG0APGE |
| Policy instance | 5 |
| Insurance contract or identification number | GLUG0APGE | | Number of Individuals Covered | 537 | | Insurance policy start date | 2020-05-01 | | Insurance policy end date | 2021-04-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $702 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $14,964 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 702 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| TRANSAMERICA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 86231 ) |
| Policy contract number | ER00024327 |
| Policy instance | 6 |
| Insurance contract or identification number | ER00024327 | | Number of Individuals Covered | 117 | | Insurance policy start date | 2020-05-01 | | Insurance policy end date | 2021-04-30 | | Total amount of commissions paid to insurance broker | USD $5,071 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | VOLUNTARY ACCIDENT | | Welfare Benefit Premiums Paid to Carrier | USD $22,014 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,245 | | Insurance broker organization code? | 3 |
|
| TRANSAMERICA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 86231 ) |
| Policy contract number | ER00024327 |
| Policy instance | 7 |
| Insurance contract or identification number | ER00024327 | | Number of Individuals Covered | 55 | | Insurance policy start date | 2020-05-01 | | Insurance policy end date | 2021-04-30 | | Total amount of commissions paid to insurance broker | USD $3,000 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | VOLUNTARY HOSPITAL | | Welfare Benefit Premiums Paid to Carrier | USD $13,515 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,681 | | Insurance broker organization code? | 3 |
|
| RELIASTAR LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 67105 ) |
| Policy contract number | EXRK 71567-1 |
| Policy instance | 8 |
| Insurance contract or identification number | EXRK 71567-1 | | Number of Individuals Covered | 363 | | Insurance policy start date | 2020-05-01 | | Insurance policy end date | 2021-04-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $36,290 | | Welfare Benefit Premiums Paid to Carrier | USD $725,909 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 36290 | | Additional information about fees paid to insurance broker | SERVICE FEE | | Insurance broker organization code? | 3 |
|
| HCC LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 92711 ) |
| Policy contract number | HCCLOT40784 |
| Policy instance | 9 |
| Insurance contract or identification number | HCCLOT40784 | | Number of Individuals Covered | 371 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $3,059 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | ORGAN TRANSPLANT | | Welfare Benefit Premiums Paid to Carrier | USD $30,594 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,059 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUG0APGE |
| Policy instance | 3 |
| Insurance contract or identification number | GUG0APGE | | Number of Individuals Covered | 26 | | Insurance policy start date | 2019-05-01 | | Insurance policy end date | 2020-04-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $154 | | Other welfare benefits provided | VOLUNTARY ST DISABILITY | | Welfare Benefit Premiums Paid to Carrier | USD $4,002 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $0 | | Amount paid for insurance broker fees | 154 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| BERKSHIRE HATHAWAY SPECIALTY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 22276 ) |
| Policy contract number | 47MSL-000068-03 |
| Policy instance | 9 |
| Insurance contract or identification number | 47MSL-000068-03 | | Number of Individuals Covered | 352 | | Insurance policy start date | 2019-05-01 | | Insurance policy end date | 2020-04-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HCC LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 92711 ) |
| Policy contract number | HCCLOT40784 |
| Policy instance | 8 |
| Insurance contract or identification number | HCCLOT40784 | | Number of Individuals Covered | 355 | | Insurance policy start date | 2019-05-01 | | Insurance policy end date | 2020-04-30 | | Total amount of commissions paid to insurance broker | USD $7,517 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | ORGAN AND TISSUE TRANSPLANT | | Welfare Benefit Premiums Paid to Carrier | USD $57,876 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,517 | | Insurance broker organization code? | 3 |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 30007652 |
| Policy instance | 1 |
| Insurance contract or identification number | 30007652 | | Number of Individuals Covered | 312 | | Insurance policy start date | 2019-05-01 | | Insurance policy end date | 2020-04-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 30056785 |
| Policy instance | 2 |
| Insurance contract or identification number | 30056785 | | Number of Individuals Covered | 264 | | Insurance policy start date | 2019-05-01 | | Insurance policy end date | 2020-04-30 | | Total amount of commissions paid to insurance broker | USD $1,868 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $50,076 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,868 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GVTL0APGE |
| Policy instance | 4 |
| Insurance contract or identification number | GVTL0APGE | | Number of Individuals Covered | 140 | | Insurance policy start date | 2019-05-01 | | Insurance policy end date | 2020-04-30 | | Total amount of commissions paid to insurance broker | USD $5,571 | | Total amount of fees paid to insurance company | USD $1,305 | | Other welfare benefits provided | VOLUNTARY LIFE AND AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $41,894 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,571 | | Amount paid for insurance broker fees | 1305 | | 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 | GLUG0APGE |
| Policy instance | 5 |
| Insurance contract or identification number | GLUG0APGE | | Number of Individuals Covered | 495 | | Insurance policy start date | 2019-05-01 | | Insurance policy end date | 2020-04-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $550 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $16,426 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 550 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| TRANSAMERICA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 86231 ) |
| Policy contract number | ER00024327 |
| Policy instance | 6 |
| Insurance contract or identification number | ER00024327 | | Number of Individuals Covered | 116 | | Insurance policy start date | 2019-05-01 | | Insurance policy end date | 2020-04-30 | | Total amount of commissions paid to insurance broker | USD $6,142 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | VOLUNTARY ACCIDENT | | Welfare Benefit Premiums Paid to Carrier | USD $24,436 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,546 | | Insurance broker organization code? | 3 |
|
| TRANSAMERICA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 86231 ) |
| Policy contract number | ER00024327 |
| Policy instance | 7 |
| Insurance contract or identification number | ER00024327 | | Number of Individuals Covered | 49 | | Insurance policy start date | 2019-05-01 | | Insurance policy end date | 2020-04-30 | | Total amount of commissions paid to insurance broker | USD $3,175 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | VOLUNTARY HOSPITAL | | Welfare Benefit Premiums Paid to Carrier | USD $13,101 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,822 | | Insurance broker organization code? | 3 |
|
| MANAGED HEALTH NETWORK (National Association of Insurance Commissioners NAIC id number: 52411 ) |
| Policy contract number | 001849 |
| Policy instance | 8 |
| Insurance contract or identification number | 001849 | | Number of Individuals Covered | 423 | | Insurance policy start date | 2018-05-01 | | Insurance policy end date | 2019-04-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | EAP | | Welfare Benefit Premiums Paid to Carrier | USD $16,968 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| TRANSAMERICA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 86231 ) |
| Policy contract number | ER00024327 |
| Policy instance | 7 |
| Insurance contract or identification number | ER00024327 | | Number of Individuals Covered | 78 | | Insurance policy start date | 2018-05-01 | | Insurance policy end date | 2019-04-30 | | Total amount of commissions paid to insurance broker | USD $4,027 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | VOLUNTARY HOSPITAL | | Welfare Benefit Premiums Paid to Carrier | USD $8,318 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,027 | | Insurance broker organization code? | 3 |
|
| TRANSAMERICA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 86231 ) |
| Policy contract number | ER00024327 |
| Policy instance | 6 |
| Insurance contract or identification number | ER00024327 | | Number of Individuals Covered | 316 | | Insurance policy start date | 2018-05-01 | | Insurance policy end date | 2019-04-30 | | Total amount of commissions paid to insurance broker | USD $7,242 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | VOLUNTARY ACCIDENT | | Welfare Benefit Premiums Paid to Carrier | USD $20,574 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,242 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG0APGE |
| Policy instance | 5 |
| Insurance contract or identification number | GLUG0APGE | | Number of Individuals Covered | 430 | | Insurance policy start date | 2018-05-01 | | Insurance policy end date | 2019-04-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $1,004 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $15,556 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 1004 | | 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 | GVTL0APGE |
| Policy instance | 4 |
| Insurance contract or identification number | GVTL0APGE | | Number of Individuals Covered | 133 | | Insurance policy start date | 2018-05-01 | | Insurance policy end date | 2019-04-30 | | Total amount of commissions paid to insurance broker | USD $5,204 | | Total amount of fees paid to insurance company | USD $2,151 | | Other welfare benefits provided | VOLUNTARY LIFE AND AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $37,815 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,723 | | Amount paid for insurance broker fees | 2151 | | 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 | GUG0APGE |
| Policy instance | 3 |
| Insurance contract or identification number | GUG0APGE | | Number of Individuals Covered | 28 | | Insurance policy start date | 2018-05-01 | | Insurance policy end date | 2019-04-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $297 | | Other welfare benefits provided | VOLUNTARY ST DISABILITY | | Welfare Benefit Premiums Paid to Carrier | USD $4,523 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 297 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 30056785 |
| Policy instance | 2 |
| Insurance contract or identification number | 30056785 | | Number of Individuals Covered | 235 | | Insurance policy start date | 2018-05-01 | | Insurance policy end date | 2019-04-30 | | Total amount of commissions paid to insurance broker | USD $1,966 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $47,329 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,578 | | Insurance broker organization code? | 3 |
|
| NATIONAL UNION (National Association of Insurance Commissioners NAIC id number: 19445 ) |
| Policy contract number | 9476614 |
| Policy instance | 9 |
| Insurance contract or identification number | 9476614 | | Number of Individuals Covered | 324 | | Insurance policy start date | 2018-05-01 | | Insurance policy end date | 2019-04-30 | | Total amount of commissions paid to insurance broker | USD $8,978 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | ORGAN AND TISSUE TRANSPLANT | | Welfare Benefit Premiums Paid to Carrier | USD $61,914 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,978 | | Insurance broker organization code? | 3 |
|
| BERKSHIRE HATHAWAY SPECIALTY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 22276 ) |
| Policy contract number | 47MSL-000068-02 |
| Policy instance | 10 |
| Insurance contract or identification number | 47MSL-000068-02 | | Number of Individuals Covered | 324 | | Insurance policy start date | 2018-05-01 | | Insurance policy end date | 2019-04-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 30007652 |
| Policy instance | 1 |
| Insurance contract or identification number | 30007652 | | Number of Individuals Covered | 248 | | Insurance policy start date | 2018-05-01 | | Insurance policy end date | 2019-04-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| BERKSHIRE HATHAWAY SPECIALTY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 22276 ) |
| Policy contract number | 47-MSL-00006801 |
| Policy instance | 1 |
| Insurance contract or identification number | 47-MSL-00006801 | | Number of Individuals Covered | 337 | | Insurance policy start date | 2017-05-01 | | Insurance policy end date | 2018-04-30 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $720,621 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| NATIONAL UNION (National Association of Insurance Commissioners NAIC id number: 19445 ) |
| Policy contract number | 947-5100 |
| Policy instance | 2 |
| Insurance contract or identification number | 947-5100 | | Number of Individuals Covered | 337 | | Insurance policy start date | 2017-05-01 | | Insurance policy end date | 2018-04-30 | | Total amount of commissions paid to insurance broker | USD $6,463 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ORGAN & TISSUE TRANSPLANT | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $64,633 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000APGE |
| Policy instance | 4 |
| Insurance contract or identification number | G000APGE | | Number of Individuals Covered | 0 | | Insurance policy start date | 2017-05-01 | | Insurance policy end date | 2018-04-30 | | Total amount of commissions paid to insurance broker | USD $4,927 | | Total amount of fees paid to insurance company | USD $899 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $34,742 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000APGE |
| Policy instance | 5 |
| Insurance contract or identification number | G000APGE | | Number of Individuals Covered | 51 | | Insurance policy start date | 2017-05-01 | | Insurance policy end date | 2018-04-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $147 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $5,993 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000APGE |
| Policy instance | 6 |
| Insurance contract or identification number | G000APGE | | Number of Individuals Covered | 230 | | Insurance policy start date | 2017-05-01 | | Insurance policy end date | 2018-04-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $387 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $13,122 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 ) |
| Policy contract number | 280400 |
| Policy instance | 7 |
| Insurance contract or identification number | 280400 | | Number of Individuals Covered | 0 | | Insurance policy start date | 2017-05-01 | | Insurance policy end date | 2018-04-30 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| AMERICAN HEALTH CARE (National Association of Insurance Commissioners NAIC id number: ) |
| Policy contract number | 8269 |
| Policy instance | 8 |
| Insurance contract or identification number | 8269 | | Number of Individuals Covered | 337 | | Insurance policy start date | 2017-05-01 | | Insurance policy end date | 2018-04-30 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 30056785 |
| Policy instance | 3 |
| Insurance contract or identification number | 30056785 | | Number of Individuals Covered | 227 | | Insurance policy start date | 2017-05-01 | | Insurance policy end date | 2018-04-30 | | Total amount of commissions paid to insurance broker | USD $1,665 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $41,215 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
