PUEBLO BANK & TRUST COMPANY has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan PUEBLO BANK & TRUST COMPANY EMPLOYEES CAFETERIA PLAN
401k plan membership statisitcs for PUEBLO BANK & TRUST COMPANY EMPLOYEES CAFETERIA PLAN
| Measure | Date | Value |
|---|
| 2022: PUEBLO BANK & TRUST COMPANY EMPLOYEES CAFETERIA PLAN 2022 401k membership |
|---|
| Total participants, beginning-of-year | 2022-01-01 | 192 |
| Total number of active participants reported on line 7a of the Form 5500 | 2022-01-01 | 176 |
| Total of all active and inactive participants | 2022-01-01 | 176 |
| 2021: PUEBLO BANK & TRUST COMPANY EMPLOYEES CAFETERIA PLAN 2021 401k membership |
|---|
| Total participants, beginning-of-year | 2021-01-01 | 199 |
| Total number of active participants reported on line 7a of the Form 5500 | 2021-01-01 | 192 |
| Total of all active and inactive participants | 2021-01-01 | 192 |
| 2020: PUEBLO BANK & TRUST COMPANY EMPLOYEES CAFETERIA PLAN 2020 401k membership |
|---|
| Total participants, beginning-of-year | 2020-01-01 | 183 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-01-01 | 199 |
| Total of all active and inactive participants | 2020-01-01 | 199 |
| 2019: PUEBLO BANK & TRUST COMPANY EMPLOYEES CAFETERIA PLAN 2019 401k membership |
|---|
| Total participants, beginning-of-year | 2019-01-01 | 161 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-01-01 | 183 |
| Total of all active and inactive participants | 2019-01-01 | 183 |
| 2018: PUEBLO BANK & TRUST COMPANY EMPLOYEES CAFETERIA PLAN 2018 401k membership |
|---|
| Total participants, beginning-of-year | 2018-01-01 | 146 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-01-01 | 161 |
| Total of all active and inactive participants | 2018-01-01 | 161 |
| 2017: PUEBLO BANK & TRUST COMPANY EMPLOYEES CAFETERIA PLAN 2017 401k membership |
|---|
| Total participants, beginning-of-year | 2017-01-01 | 137 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-01-01 | 146 |
| Total of all active and inactive participants | 2017-01-01 | 146 |
| 2016: PUEBLO BANK & TRUST COMPANY EMPLOYEES CAFETERIA PLAN 2016 401k membership |
|---|
| Total participants, beginning-of-year | 2016-01-01 | 125 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-01-01 | 137 |
| Total of all active and inactive participants | 2016-01-01 | 137 |
| Total participants | 2016-01-01 | 137 |
| 2015: PUEBLO BANK & TRUST COMPANY EMPLOYEES CAFETERIA PLAN 2015 401k membership |
|---|
| Total participants, beginning-of-year | 2015-01-01 | 121 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-01-01 | 125 |
| Total of all active and inactive participants | 2015-01-01 | 125 |
| 2014: PUEBLO BANK & TRUST COMPANY EMPLOYEES CAFETERIA PLAN 2014 401k membership |
|---|
| Total participants, beginning-of-year | 2014-01-01 | 125 |
| Total number of active participants reported on line 7a of the Form 5500 | 2014-01-01 | 121 |
| Total of all active and inactive participants | 2014-01-01 | 121 |
| 2013: PUEBLO BANK & TRUST COMPANY EMPLOYEES CAFETERIA PLAN 2013 401k membership |
|---|
| Total participants, beginning-of-year | 2013-01-01 | 150 |
| Total number of active participants reported on line 7a of the Form 5500 | 2013-01-01 | 125 |
| Total of all active and inactive participants | 2013-01-01 | 125 |
| 2012: PUEBLO BANK & TRUST COMPANY EMPLOYEES CAFETERIA PLAN 2012 401k membership |
|---|
| Total participants, beginning-of-year | 2012-01-01 | 168 |
| Total number of active participants reported on line 7a of the Form 5500 | 2012-01-01 | 150 |
| Total of all active and inactive participants | 2012-01-01 | 150 |
| 2011: PUEBLO BANK & TRUST COMPANY EMPLOYEES CAFETERIA PLAN 2011 401k membership |
|---|
| Total participants, beginning-of-year | 2011-01-01 | 191 |
| Total number of active participants reported on line 7a of the Form 5500 | 2011-01-01 | 168 |
| Total of all active and inactive participants | 2011-01-01 | 168 |
| 2010: PUEBLO BANK & TRUST COMPANY EMPLOYEES CAFETERIA PLAN 2010 401k membership |
|---|
| Total participants, beginning-of-year | 2010-01-01 | 223 |
| Total number of active participants reported on line 7a of the Form 5500 | 2010-01-01 | 191 |
| Total of all active and inactive participants | 2010-01-01 | 191 |
| 2009: PUEBLO BANK & TRUST COMPANY EMPLOYEES CAFETERIA PLAN 2009 401k membership |
|---|
| Total participants, beginning-of-year | 2009-01-01 | 192 |
| Total number of active participants reported on line 7a of the Form 5500 | 2009-01-01 | 223 |
| Total of all active and inactive participants | 2009-01-01 | 223 |
| Measure | Date | Value |
|---|
| 2022 : PUEBLO BANK & TRUST COMPANY EMPLOYEES CAFETERIA PLAN 2022 401k financial data |
|---|
| Total income from all sources (including contributions) | 2022-12-31 | $1,131,029 |
| Total of all expenses incurred | 2022-12-31 | $1,131,029 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2022-12-31 | $1,076,752 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2022-12-31 | $1,131,029 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2022-12-31 | $54,277 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2022-12-31 | No |
| Was this plan covered by a fidelity bond | 2022-12-31 | No |
| If this is an individual account plan, was there a blackout period | 2022-12-31 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2022-12-31 | No |
| Administrative expenses (other) incurred | 2022-12-31 | $54,277 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2022-12-31 | No |
| Value of net income/loss | 2022-12-31 | $0 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2022-12-31 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2022-12-31 | No |
| Were any leases to which the plan was party in default or uncollectible | 2022-12-31 | No |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2022-12-31 | $1,076,752 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2022-12-31 | No |
| Was there a failure to transmit to the plan any participant contributions | 2022-12-31 | No |
| Has the plan failed to provide any benefit when due under the plan | 2022-12-31 | No |
| Contributions received in cash from employer | 2022-12-31 | $1,131,029 |
| 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 | 2022-12-31 | No |
| Did the plan have assets held for investment | 2022-12-31 | 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 | 2022-12-31 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2022-12-31 | No |
| 2021 : PUEBLO BANK & TRUST COMPANY EMPLOYEES CAFETERIA PLAN 2021 401k financial data |
|---|
| Total income from all sources (including contributions) | 2021-12-31 | $974,153 |
| Total of all expenses incurred | 2021-12-31 | $974,153 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2021-12-31 | $920,132 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2021-12-31 | $974,153 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2021-12-31 | $54,021 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2021-12-31 | No |
| Was this plan covered by a fidelity bond | 2021-12-31 | No |
| If this is an individual account plan, was there a blackout period | 2021-12-31 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2021-12-31 | No |
| Administrative expenses (other) incurred | 2021-12-31 | $54,021 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2021-12-31 | No |
| Value of net income/loss | 2021-12-31 | $0 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2021-12-31 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2021-12-31 | No |
| Were any leases to which the plan was party in default or uncollectible | 2021-12-31 | No |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2021-12-31 | $920,132 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2021-12-31 | No |
| Was there a failure to transmit to the plan any participant contributions | 2021-12-31 | No |
| Has the plan failed to provide any benefit when due under the plan | 2021-12-31 | No |
| Contributions received in cash from employer | 2021-12-31 | $974,153 |
| 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 | 2021-12-31 | No |
| Did the plan have assets held for investment | 2021-12-31 | 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 | 2021-12-31 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2021-12-31 | No |
| 2020 : PUEBLO BANK & TRUST COMPANY EMPLOYEES CAFETERIA PLAN 2020 401k financial data |
|---|
| Total income from all sources (including contributions) | 2020-12-31 | $1,078,442 |
| Total of all expenses incurred | 2020-12-31 | $1,078,442 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2020-12-31 | $1,026,579 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2020-12-31 | $1,078,442 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2020-12-31 | $51,863 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2020-12-31 | No |
| Was this plan covered by a fidelity bond | 2020-12-31 | No |
| If this is an individual account plan, was there a blackout period | 2020-12-31 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2020-12-31 | No |
| Administrative expenses (other) incurred | 2020-12-31 | $51,863 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2020-12-31 | No |
| Value of net income/loss | 2020-12-31 | $0 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2020-12-31 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2020-12-31 | No |
| Were any leases to which the plan was party in default or uncollectible | 2020-12-31 | No |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2020-12-31 | $1,026,579 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2020-12-31 | No |
| Was there a failure to transmit to the plan any participant contributions | 2020-12-31 | No |
| Has the plan failed to provide any benefit when due under the plan | 2020-12-31 | No |
| Contributions received in cash from employer | 2020-12-31 | $1,078,442 |
| 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 | 2020-12-31 | No |
| Did the plan have assets held for investment | 2020-12-31 | 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 | 2020-12-31 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2020-12-31 | No |
| 2022: PUEBLO BANK & TRUST COMPANY EMPLOYEES CAFETERIA PLAN 2022 form 5500 responses |
|---|
| 2022-01-01 | Type of plan entity | Single employer plan |
| 2022-01-01 | Plan funding arrangement – Insurance | Yes |
| 2022-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2022-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2022-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2021: PUEBLO BANK & TRUST COMPANY EMPLOYEES CAFETERIA PLAN 2021 form 5500 responses |
|---|
| 2021-01-01 | Type of plan entity | Single employer plan |
| 2021-01-01 | Plan funding arrangement – Insurance | Yes |
| 2021-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2021-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2021-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2020: PUEBLO BANK & TRUST COMPANY EMPLOYEES CAFETERIA PLAN 2020 form 5500 responses |
|---|
| 2020-01-01 | Type of plan entity | Single employer plan |
| 2020-01-01 | Plan funding arrangement – Insurance | Yes |
| 2020-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2020-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2020-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2019: PUEBLO BANK & TRUST COMPANY EMPLOYEES CAFETERIA PLAN 2019 form 5500 responses |
|---|
| 2019-01-01 | Type of plan entity | Single employer plan |
| 2019-01-01 | Plan funding arrangement – Insurance | Yes |
| 2019-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2019-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2019-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2018: PUEBLO BANK & TRUST COMPANY EMPLOYEES CAFETERIA PLAN 2018 form 5500 responses |
|---|
| 2018-01-01 | Type of plan entity | Single employer plan |
| 2018-01-01 | Plan funding arrangement – Insurance | Yes |
| 2018-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2018-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2018-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2017: PUEBLO BANK & TRUST COMPANY EMPLOYEES CAFETERIA PLAN 2017 form 5500 responses |
|---|
| 2017-01-01 | Type of plan entity | Single employer plan |
| 2017-01-01 | Plan funding arrangement – Insurance | Yes |
| 2017-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2017-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2017-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2016: PUEBLO BANK & TRUST COMPANY EMPLOYEES CAFETERIA PLAN 2016 form 5500 responses |
|---|
| 2016-01-01 | Type of plan entity | Single employer plan |
| 2016-01-01 | Plan funding arrangement – Insurance | Yes |
| 2016-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2016-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2016-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2015: PUEBLO BANK & TRUST COMPANY EMPLOYEES CAFETERIA PLAN 2015 form 5500 responses |
|---|
| 2015-01-01 | Type of plan entity | Single employer plan |
| 2015-01-01 | Plan funding arrangement – Insurance | Yes |
| 2015-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2015-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2015-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2014: PUEBLO BANK & TRUST COMPANY EMPLOYEES CAFETERIA PLAN 2014 form 5500 responses |
|---|
| 2014-01-01 | Type of plan entity | Single employer plan |
| 2014-01-01 | Plan funding arrangement – Insurance | Yes |
| 2014-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2014-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2014-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2013: PUEBLO BANK & TRUST COMPANY EMPLOYEES CAFETERIA PLAN 2013 form 5500 responses |
|---|
| 2013-01-01 | Type of plan entity | Single employer plan |
| 2013-01-01 | Plan funding arrangement – Insurance | Yes |
| 2013-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2013-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2013-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2012: PUEBLO BANK & TRUST COMPANY EMPLOYEES CAFETERIA PLAN 2012 form 5500 responses |
|---|
| 2012-01-01 | Type of plan entity | Single employer plan |
| 2012-01-01 | Plan funding arrangement – Insurance | Yes |
| 2012-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2012-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2012-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2011: PUEBLO BANK & TRUST COMPANY EMPLOYEES CAFETERIA PLAN 2011 form 5500 responses |
|---|
| 2011-01-01 | Type of plan entity | Single employer plan |
| 2011-01-01 | Plan funding arrangement – Insurance | Yes |
| 2011-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2011-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2011-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2010: PUEBLO BANK & TRUST COMPANY EMPLOYEES CAFETERIA PLAN 2010 form 5500 responses |
|---|
| 2010-01-01 | Type of plan entity | Single employer plan |
| 2010-01-01 | Plan funding arrangement – Insurance | Yes |
| 2010-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2010-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2010-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2009: PUEBLO BANK & TRUST COMPANY EMPLOYEES CAFETERIA PLAN 2009 form 5500 responses |
|---|
| 2009-01-01 | Type of plan entity | Single employer plan |
| 2009-01-01 | This submission is the final filing | No |
| 2009-01-01 | Plan funding arrangement – Insurance | Yes |
| 2009-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2009-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2009-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| ROCKY MOUNTAIN HOSPITAL AND MEDICAL SERVICE, INC. (National Association of Insurance Commissioners NAIC id number: 11011 ) |
| Policy contract number | 196568 |
| Policy instance | 1 |
| Insurance contract or identification number | 196568 | | Number of Individuals Covered | 176 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $8,250 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $81,833 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,250 | | Insurance broker organization code? | 3 |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 0922762 |
| Policy instance | 5 |
| Insurance contract or identification number | 0922762 | | Number of Individuals Covered | 101 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $34,406 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $888,470 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $34,406 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 911134 |
| Policy instance | 4 |
| Insurance contract or identification number | 911134 | | Number of Individuals Covered | 129 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $6,446 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $61,015 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,446 | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 911135 |
| Policy instance | 3 |
| Insurance contract or identification number | 911135 | | Number of Individuals Covered | 50 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $2,632 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $16,715 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,632 | | Insurance broker organization code? | 3 |
|
| COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 ) |
| Policy contract number | E5003595 |
| Policy instance | 2 |
| Insurance contract or identification number | E5003595 | | Number of Individuals Covered | 38 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $2,444 | | Total amount of fees paid to insurance company | USD $99 | | Temporary Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | SUPPLEMENTAL PLANS | | Welfare Benefit Premiums Paid to Carrier | USD $28,719 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,644 | | Amount paid for insurance broker fees | 99 | | Insurance broker organization code? | 3 |
|
| COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 ) |
| Policy contract number | E5003595 |
| Policy instance | 2 |
| Insurance contract or identification number | E5003595 | | Number of Individuals Covered | 47 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $3,988 | | Total amount of fees paid to insurance company | USD $266 | | Temporary Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | SUPPLEMENTAL PLANS | | Welfare Benefit Premiums Paid to Carrier | USD $29,853 | | 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 | | Amount paid for insurance broker fees | 265 | | Insurance broker organization code? | 3 |
|
| ROCKY MOUNTAIN HOSPITAL AND MEDICAL SERVICE, INC. (National Association of Insurance Commissioners NAIC id number: 11011 ) |
| Policy contract number | 196568 |
| Policy instance | 1 |
| Insurance contract or identification number | 196568 | | Number of Individuals Covered | 192 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $10,731 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $80,678 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $10,731 | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 911134 |
| Policy instance | 4 |
| Insurance contract or identification number | 911134 | | Number of Individuals Covered | 136 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $5,402 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $54,969 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,402 | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 911135 |
| Policy instance | 3 |
| Insurance contract or identification number | 911135 | | Number of Individuals Covered | 60 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $2,582 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $17,214 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,582 | | Insurance broker organization code? | 3 |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 0922762 |
| Policy instance | 5 |
| Insurance contract or identification number | 0922762 | | Number of Individuals Covered | 97 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $31,052 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $737,418 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $31,052 |
|
| COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 ) |
| Policy contract number | E5003595 |
| Policy instance | 2 |
| Insurance contract or identification number | E5003595 | | Number of Individuals Covered | 45 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $3,581 | | Total amount of fees paid to insurance company | USD $235 | | Temporary Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | SUPPLEMENTAL PLANS | | Welfare Benefit Premiums Paid to Carrier | USD $29,769 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,758 | | Amount paid for insurance broker fees | 24 | | Insurance broker organization code? | 3 |
|
| ROCKY MOUNTAIN HOSPITAL AND MEDICAL SERVICE, INC. (National Association of Insurance Commissioners NAIC id number: 11011 ) |
| Policy contract number | 196568 |
| Policy instance | 1 |
| Insurance contract or identification number | 196568 | | Number of Individuals Covered | 199 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $39,965 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $935,896 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $39,965 | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 911135 |
| Policy instance | 3 |
| Insurance contract or identification number | 911135 | | Number of Individuals Covered | 58 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $2,484 | | Total amount of fees paid to insurance company | USD $124 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $15,238 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,484 | | Amount paid for insurance broker fees | 124 | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 911134 |
| Policy instance | 4 |
| Insurance contract or identification number | 911134 | | Number of Individuals Covered | 126 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $5,100 | | Total amount of fees paid to insurance company | USD $374 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $45,676 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,100 | | Amount paid for insurance broker fees | 374 | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 911135 |
| Policy instance | 3 |
| Insurance contract or identification number | 911135 | | Number of Individuals Covered | 56 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $2,091 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $13,632 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,091 | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 911134 |
| Policy instance | 4 |
| Insurance contract or identification number | 911134 | | Number of Individuals Covered | 119 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $4,683 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $41,609 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,683 | | Insurance broker organization code? | 3 |
|
| ROCKY MOUNTAIN HOSPITAL AND MEDICAL SERVICE, INC. (National Association of Insurance Commissioners NAIC id number: 11011 ) |
| Policy contract number | 196568 |
| Policy instance | 1 |
| Insurance contract or identification number | 196568 | | Number of Individuals Covered | 183 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $36,820 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $978,812 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $36,820 | | Insurance broker organization code? | 3 |
|
| COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 ) |
| Policy contract number | E5003595 |
| Policy instance | 2 |
| Insurance contract or identification number | E5003595 | | Number of Individuals Covered | 44 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $6,340 | | Total amount of fees paid to insurance company | USD $689 | | Temporary Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | SUPPLEMENTAL PLANS | | Welfare Benefit Premiums Paid to Carrier | USD $29,056 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,663 | | Amount paid for insurance broker fees | 689 | | Insurance broker organization code? | 3 |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 648876 |
| Policy instance | 1 |
| Insurance contract or identification number | 648876 | | Number of Individuals Covered | 125 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $23,386 | | Total amount of fees paid to insurance company | USD $1,218 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $537,436 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $23,386 | | Amount paid for insurance broker fees | 1218 | | Insurance broker organization code? | 3 | | Insurance broker name | BENEFITS BROKER INC |
|
| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
| Policy contract number | KM05932411 |
| Policy instance | 2 |
| Insurance contract or identification number | KM05932411 | | Number of Individuals Covered | 182 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $6,749 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $46,027 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,749 | | Insurance broker organization code? | 3 | | Insurance broker name | BENEFITS BROKER INC |
|
| DELTA DENTAL OF COLORADO (National Association of Insurance Commissioners NAIC id number: 55875 ) |
| Policy contract number | 8356 |
| Policy instance | 3 |
| Insurance contract or identification number | 8356 | | Number of Individuals Covered | 146 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $2,511 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $50,599 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,511 | | Insurance broker organization code? | 3 | | Insurance broker name | BENEFITS BROKER INC |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 30005320 |
| Policy instance | 4 |
| Insurance contract or identification number | 30005320 | | Number of Individuals Covered | 45 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $608 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $7,151 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $608 | | Insurance broker organization code? | 3 | | Insurance broker name | BENEFITS BROKER INC |
|
| DELTA DENTAL OF COLORADO (National Association of Insurance Commissioners NAIC id number: 55875 ) |
| Policy contract number | 8356 |
| Policy instance | 3 |
| Insurance contract or identification number | 8356 | | Number of Individuals Covered | 125 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $2,239 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $44,127 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,239 | | Insurance broker organization code? | 3 | | Insurance broker name | BENEFITS BROKER INC |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AC7F |
| Policy instance | 2 |
| Insurance contract or identification number | G000AC7F | | Number of Individuals Covered | 207 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $4,593 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $40,900 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,593 | | Insurance broker organization code? | 3 | | Insurance broker name | BENEFITS BROKER INC |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 648876 |
| Policy instance | 1 |
| Insurance contract or identification number | 648876 | | Number of Individuals Covered | 97 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $18,805 | | Total amount of fees paid to insurance company | USD $1,087 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $506,533 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $18,805 | | Amount paid for insurance broker fees | 1087 | | Additional information about fees paid to insurance broker | BONUS | | Insurance broker organization code? | 3 | | Insurance broker name | BENEFITS BROKER INC |
|
| DELTA DENTAL OF COLORADO (National Association of Insurance Commissioners NAIC id number: 55875 ) |
| Policy contract number | 8356 |
| Policy instance | 4 |
| Insurance contract or identification number | 8356 | | Number of Individuals Covered | 159 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $2,358 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $47,303 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,358 | | Insurance broker organization code? | 3 | | Insurance broker name | BENEFITS BROKER INC |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 648876 |
| Policy instance | 2 |
| Insurance contract or identification number | 648876 | | Number of Individuals Covered | 121 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $20,533 | | Total amount of fees paid to insurance company | USD $515 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $467,988 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $20,533 | | Amount paid for insurance broker fees | 515 | | Additional information about fees paid to insurance broker | BONUS | | Insurance broker organization code? | 3 | | Insurance broker name | BENEFITS BROKER INC |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 30005320 |
| Policy instance | 1 |
| Insurance contract or identification number | 30005320 | | Number of Individuals Covered | 48 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $665 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $8,296 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $665 | | Insurance broker organization code? | 3 | | Insurance broker name | BENEFITS BROKER INC |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AC7F |
| Policy instance | 3 |
| Insurance contract or identification number | G000AC7F | | Number of Individuals Covered | 213 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $4,555 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $40,635 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,555 | | Insurance broker organization code? | 3 | | Insurance broker name | BENEFITS BROKER INC |
|
| DELTA DENTAL OF COLORADO (National Association of Insurance Commissioners NAIC id number: 55875 ) |
| Policy contract number | 8356 |
| Policy instance | 4 |
| Insurance contract or identification number | 8356 | | Number of Individuals Covered | 164 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $2,401 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $47,658 | | 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 | | Insurance broker organization code? | 3 | | Insurance broker name | BENEFITS BROKER INC |
|
| ROCKY MOUNTAIN HEALTH CARE OPTIONS, INC. (National Association of Insurance Commissioners NAIC id number: 47004 ) |
| Policy contract number | 16054000 |
| Policy instance | 2 |
| Insurance contract or identification number | 16054000 | | Number of Individuals Covered | 125 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $11,355 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $538,249 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $11,355 | | Insurance broker organization code? | 3 | | Insurance broker name | BENEFITS BROKER INC |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AC7F |
| Policy instance | 3 |
| Insurance contract or identification number | G000AC7F | | Number of Individuals Covered | 217 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $4,255 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $37,702 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,255 | | Insurance broker organization code? | 3 | | Insurance broker name | BENEFITS BROKER INC |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 30005320 |
| Policy instance | 1 |
| Insurance contract or identification number | 30005320 | | Number of Individuals Covered | 50 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $630 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $7,601 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $630 | | Insurance broker organization code? | 3 | | Insurance broker name | BENEFITS BROKER INC |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AC7F |
| Policy instance | 3 |
| Insurance contract or identification number | G000AC7F | | Number of Individuals Covered | 224 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $4,435 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $39,245 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,435 | | Insurance broker organization code? | 3 | | Insurance broker name | BENEFITS BROKER INC |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 30005320 |
| Policy instance | 1 |
| Insurance contract or identification number | 30005320 | | Number of Individuals Covered | 51 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $685 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $8,703 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $685 | | Insurance broker organization code? | 3 | | Insurance broker name | BENEFITS BROKER INC |
|
| DELTA DENTAL OF COLORADO (National Association of Insurance Commissioners NAIC id number: 55875 ) |
| Policy contract number | 8356 |
| Policy instance | 4 |
| Insurance contract or identification number | 8356 | | Number of Individuals Covered | 181 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $2,762 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,762 | | Insurance broker organization code? | 3 | | Insurance broker name | BENEFITS BROKER INC |
|
| ROCKY MOUNTAIN HEALTH CARE OPTIONS, INC. (National Association of Insurance Commissioners NAIC id number: 47004 ) |
| Policy contract number | 16054000 |
| Policy instance | 2 |
| Insurance contract or identification number | 16054000 | | Number of Individuals Covered | 150 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $13,140 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $594,126 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $13,140 | | Insurance broker organization code? | 3 | | Insurance broker name | BENEFITS BROKER INC |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 30005320 |
| Policy instance | 1 |
| Insurance contract or identification number | 30005320 | | Number of Individuals Covered | 53 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2011-12-31 | | Total amount of commissions paid to insurance broker | USD $677 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $8,535 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| ROCKY MOUNTAIN HEALTH MAINTENANCE ORGANIZATION INC. (National Association of Insurance Commissioners NAIC id number: 95482 ) |
| Policy contract number | 16054000 |
| Policy instance | 2 |
| Insurance contract or identification number | 16054000 | | Number of Individuals Covered | 168 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2011-12-31 | | Total amount of commissions paid to insurance broker | USD $14,055 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $568,408 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| DELTA DENTAL OF COLORADO (National Association of Insurance Commissioners NAIC id number: 55875 ) |
| Policy contract number | 8356 |
| Policy instance | 4 |
| Insurance contract or identification number | 8356 | | Number of Individuals Covered | 190 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2011-12-31 | | Total amount of commissions paid to insurance broker | USD $3,035 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Dental Insurance Welfare Benefit | Yes | | 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 | G000AC7F |
| Policy instance | 3 |
| Insurance contract or identification number | G000AC7F | | Number of Individuals Covered | 235 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2011-12-31 | | Total amount of commissions paid to insurance broker | USD $4,214 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $36,839 | | 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: 39616 ) |
| Policy contract number | 30005320 |
| Policy instance | 1 |
| Insurance contract or identification number | 30005320 | | Number of Individuals Covered | 56 | | Insurance policy start date | 2010-01-01 | | Insurance policy end date | 2010-12-31 | | Total amount of commissions paid to insurance broker | USD $742 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $9,843 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $742 | | Insurance broker organization code? | 3 | | Insurance broker name | BENEFIT BROKER INC |
|
| ROCKY MOUNTAIN HEALTH MAINTENANCE ORGANIZATION INC. (National Association of Insurance Commissioners NAIC id number: 95482 ) |
| Policy contract number | 16054000 |
| Policy instance | 2 |
| Insurance contract or identification number | 16054000 | | Number of Individuals Covered | 191 | | Insurance policy start date | 2010-01-01 | | Insurance policy end date | 2010-12-31 | | Total amount of commissions paid to insurance broker | USD $17,670 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $648,604 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $17,670 | | Insurance broker organization code? | 3 | | Insurance broker name | BENEFIT BROKER INC |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AC7F |
| Policy instance | 4 |
| Insurance contract or identification number | G000AC7F | | Number of Individuals Covered | 264 | | Insurance policy start date | 2010-01-01 | | Insurance policy end date | 2010-12-31 | | Total amount of commissions paid to insurance broker | USD $4,912 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $42,996 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,912 | | Insurance broker organization code? | 3 | | Insurance broker name | BENEFIT BROKER INC |
|
| DELTA DENTAL OF COLORADO (National Association of Insurance Commissioners NAIC id number: 55875 ) |
| Policy contract number | 8356 |
| Policy instance | 5 |
| Insurance contract or identification number | 8356 | | Number of Individuals Covered | 210 | | Insurance policy start date | 2010-01-01 | | Insurance policy end date | 2010-12-31 | | Total amount of commissions paid to insurance broker | USD $3,159 | | Total amount of fees paid to insurance company | USD $6,304 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,159 | | Amount paid for insurance broker fees | 6304 | | Additional information about fees paid to insurance broker | DENTAL SERVICE ADMINISTRATIVE FEES | | Insurance broker organization code? | 3 | | Insurance broker name | BENEFIT BROKER INC |
|
| GREAT-WEST LIFE & ANNUITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68322 ) |
| Policy contract number | 605126 |
| Policy instance | 3 |
| Insurance contract or identification number | 605126 | | Number of Individuals Covered | 156 | | Insurance policy start date | 2010-01-01 | | Insurance policy end date | 2010-12-31 | | Total amount of commissions paid to insurance broker | USD $3,448 | | Total amount of fees paid to insurance company | USD $1,013 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,448 | | Amount paid for insurance broker fees | 1013 | | Additional information about fees paid to insurance broker | MEDICAL INSURANCE ADMINISTRATIVE FEES | | Insurance broker organization code? | 3 | | Insurance broker name | BENEFITS BROKER INC |
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