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MOUNTAIN FAMILY HEALTH AND WELFARE PLAN 401k Plan overview

Plan NameMOUNTAIN FAMILY HEALTH AND WELFARE PLAN
Plan identification number 501

MOUNTAIN FAMILY HEALTH AND WELFARE PLAN Benefits

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

401k Sponsoring company profile

MOUNTAIN FAMILY HEALTH CENTERS has sponsored the creation of one or more 401k plans.

Company Name:MOUNTAIN FAMILY HEALTH CENTERS
Employer identification number (EIN):840742145
NAIC Classification:621399
NAIC Description:Offices of All Other Miscellaneous Health Practitioners

Additional information about MOUNTAIN FAMILY HEALTH CENTERS

Jurisdiction of Incorporation: Colorado Department of State
Incorporation Date: 1977-08-08
Company Identification Number: 19871330778
Legal Registered Office Address: 2700 Gilstrap Ct, @100

Glenwood Springs
United States of America (USA)
81601

More information about MOUNTAIN FAMILY HEALTH CENTERS

Form 5500 Filing Information

Submission information for form 5500 for 401k plan MOUNTAIN FAMILY HEALTH AND WELFARE PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5012022-01-01ANNETTE FRANTA2023-05-21
5012021-06-01ANNETTE FRANTA2022-06-30
5012020-06-01ANNETTE FRANTA2021-10-29
5012019-06-01SCOTT OWENS2021-03-30
5012018-06-01SCOTT OWENS2020-02-10
5012017-06-01
5012016-06-01
5012015-06-01SCOTT M OWENS

Plan Statistics for MOUNTAIN FAMILY HEALTH AND WELFARE PLAN

401k plan membership statisitcs for MOUNTAIN FAMILY HEALTH AND WELFARE PLAN

Measure Date Value
2022: MOUNTAIN FAMILY HEALTH AND WELFARE PLAN 2022 401k membership
Total participants, beginning-of-year2022-01-01160
Total number of active participants reported on line 7a of the Form 55002022-01-01162
Number of retired or separated participants receiving benefits2022-01-012
Number of other retired or separated participants entitled to future benefits2022-01-010
Total of all active and inactive participants2022-01-01164
Number of employers contributing to the scheme2022-01-010
2021: MOUNTAIN FAMILY HEALTH AND WELFARE PLAN 2021 401k membership
Total participants, beginning-of-year2021-06-01161
Total number of active participants reported on line 7a of the Form 55002021-06-01157
Number of retired or separated participants receiving benefits2021-06-013
Number of other retired or separated participants entitled to future benefits2021-06-010
Total of all active and inactive participants2021-06-01160
Number of employers contributing to the scheme2021-06-010
2020: MOUNTAIN FAMILY HEALTH AND WELFARE PLAN 2020 401k membership
Total participants, beginning-of-year2020-06-01150
Total number of active participants reported on line 7a of the Form 55002020-06-01158
Number of retired or separated participants receiving benefits2020-06-013
Number of other retired or separated participants entitled to future benefits2020-06-010
Total of all active and inactive participants2020-06-01161
Number of employers contributing to the scheme2020-06-010
2019: MOUNTAIN FAMILY HEALTH AND WELFARE PLAN 2019 401k membership
Total participants, beginning-of-year2019-06-01163
Total number of active participants reported on line 7a of the Form 55002019-06-01149
Number of retired or separated participants receiving benefits2019-06-011
Number of other retired or separated participants entitled to future benefits2019-06-010
Total of all active and inactive participants2019-06-01150
Number of employers contributing to the scheme2019-06-010
2018: MOUNTAIN FAMILY HEALTH AND WELFARE PLAN 2018 401k membership
Total participants, beginning-of-year2018-06-01136
Total number of active participants reported on line 7a of the Form 55002018-06-01163
Number of retired or separated participants receiving benefits2018-06-010
Number of other retired or separated participants entitled to future benefits2018-06-010
Total of all active and inactive participants2018-06-01163
Number of employers contributing to the scheme2018-06-010
2017: MOUNTAIN FAMILY HEALTH AND WELFARE PLAN 2017 401k membership
Total participants, beginning-of-year2017-06-01154
Total number of active participants reported on line 7a of the Form 55002017-06-01135
Number of retired or separated participants receiving benefits2017-06-011
Number of other retired or separated participants entitled to future benefits2017-06-010
Total of all active and inactive participants2017-06-01136
2016: MOUNTAIN FAMILY HEALTH AND WELFARE PLAN 2016 401k membership
Total participants, beginning-of-year2016-06-01125
Total number of active participants reported on line 7a of the Form 55002016-06-01154
Number of retired or separated participants receiving benefits2016-06-010
Number of other retired or separated participants entitled to future benefits2016-06-010
Total of all active and inactive participants2016-06-01154
2015: MOUNTAIN FAMILY HEALTH AND WELFARE PLAN 2015 401k membership
Total participants, beginning-of-year2015-06-01106
Total number of active participants reported on line 7a of the Form 55002015-06-01125
Number of retired or separated participants receiving benefits2015-06-010
Number of other retired or separated participants entitled to future benefits2015-06-010
Total of all active and inactive participants2015-06-01125

Form 5500 Responses for MOUNTAIN FAMILY HEALTH AND WELFARE PLAN

2022: MOUNTAIN FAMILY HEALTH AND WELFARE PLAN 2022 form 5500 responses
2022-01-01Type of plan entitySingle employer plan
2022-01-01Plan funding arrangement – InsuranceYes
2022-01-01Plan funding arrangement – General assets of the sponsorYes
2022-01-01Plan benefit arrangement – InsuranceYes
2022-01-01Plan benefit arrangement – General assets of the sponsorYes
2021: MOUNTAIN FAMILY HEALTH AND WELFARE PLAN 2021 form 5500 responses
2021-06-01Type of plan entitySingle employer plan
2021-06-01This return/report is a short plan year return/report (less than 12 months)Yes
2021-06-01Plan funding arrangement – InsuranceYes
2021-06-01Plan funding arrangement – General assets of the sponsorYes
2021-06-01Plan benefit arrangement – InsuranceYes
2021-06-01Plan benefit arrangement – General assets of the sponsorYes
2020: MOUNTAIN FAMILY HEALTH AND WELFARE PLAN 2020 form 5500 responses
2020-06-01Type of plan entitySingle employer plan
2020-06-01Plan funding arrangement – InsuranceYes
2020-06-01Plan funding arrangement – General assets of the sponsorYes
2020-06-01Plan benefit arrangement – InsuranceYes
2020-06-01Plan benefit arrangement – General assets of the sponsorYes
2019: MOUNTAIN FAMILY HEALTH AND WELFARE PLAN 2019 form 5500 responses
2019-06-01Type of plan entitySingle employer plan
2019-06-01Plan funding arrangement – InsuranceYes
2019-06-01Plan funding arrangement – General assets of the sponsorYes
2019-06-01Plan benefit arrangement – InsuranceYes
2019-06-01Plan benefit arrangement – General assets of the sponsorYes
2018: MOUNTAIN FAMILY HEALTH AND WELFARE PLAN 2018 form 5500 responses
2018-06-01Type of plan entitySingle employer plan
2018-06-01Plan funding arrangement – InsuranceYes
2018-06-01Plan funding arrangement – General assets of the sponsorYes
2018-06-01Plan benefit arrangement – InsuranceYes
2018-06-01Plan benefit arrangement – General assets of the sponsorYes
2017: MOUNTAIN FAMILY HEALTH AND WELFARE PLAN 2017 form 5500 responses
2017-06-01Type of plan entitySingle employer plan
2017-06-01Plan funding arrangement – InsuranceYes
2017-06-01Plan funding arrangement – General assets of the sponsorYes
2017-06-01Plan benefit arrangement – InsuranceYes
2017-06-01Plan benefit arrangement – General assets of the sponsorYes
2016: MOUNTAIN FAMILY HEALTH AND WELFARE PLAN 2016 form 5500 responses
2016-06-01Type of plan entitySingle employer plan
2016-06-01Submission has been amendedNo
2016-06-01This submission is the final filingNo
2016-06-01This return/report is a short plan year return/report (less than 12 months)No
2016-06-01Plan is a collectively bargained planNo
2016-06-01Plan funding arrangement – InsuranceYes
2016-06-01Plan funding arrangement – General assets of the sponsorYes
2016-06-01Plan benefit arrangement – InsuranceYes
2016-06-01Plan benefit arrangement – General assets of the sponsorYes
2015: MOUNTAIN FAMILY HEALTH AND WELFARE PLAN 2015 form 5500 responses
2015-06-01Type of plan entitySingle employer plan
2015-06-01First time form 5500 has been submittedYes
2015-06-01Submission has been amendedNo
2015-06-01This submission is the final filingNo
2015-06-01This return/report is a short plan year return/report (less than 12 months)No
2015-06-01Plan is a collectively bargained planNo
2015-06-01Plan funding arrangement – InsuranceYes
2015-06-01Plan funding arrangement – General assets of the sponsorYes
2015-06-01Plan benefit arrangement – InsuranceYes
2015-06-01Plan benefit arrangement – General assets of the sponsorYes

Insurance Providers Used on plan

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGVTL0BCGG
Policy instance 4
Insurance contract or identification numberGVTL0BCGG
Number of Individuals Covered162
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $1,924
Total amount of fees paid to insurance companyUSD $1,014
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $13,451
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,924
Amount paid for insurance broker fees1014
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
TRIAD RESOURCE GROUP, LLC DBA TRIAD EAP (National Association of Insurance Commissioners NAIC id number: 62419 )
Policy contract numberMF1
Policy instance 3
Insurance contract or identification numberMF1
Number of Individuals Covered171
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedEMPLOYEE ASSISTANCE PROGRAM
Welfare Benefit Premiums Paid to CarrierUSD $10,317
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )
Policy contract numberKHT14
Policy instance 2
Insurance contract or identification numberKHT14
Number of Individuals Covered30
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $4,366
Total amount of fees paid to insurance companyUSD $327
Temporary Disability Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENT, CRITICAL ILLNESS, HOSPITAL, CANCER
Welfare Benefit Premiums Paid to CarrierUSD $37,338
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,133
Amount paid for insurance broker fees202
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number12065303
Policy instance 1
Insurance contract or identification number12065303
Number of Individuals Covered133
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $1,218
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $23,727
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,218
Amount paid for insurance broker fees0
Insurance broker organization code?3
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number12065303
Policy instance 1
Insurance contract or identification number12065303
Number of Individuals Covered142
Insurance policy start date2021-06-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $489
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $14,487
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $489
Amount paid for insurance broker fees0
Insurance broker organization code?3
AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )
Policy contract numberKHT14
Policy instance 2
Insurance contract or identification numberKHT14
Number of Individuals Covered36
Insurance policy start date2021-06-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $2,895
Total amount of fees paid to insurance companyUSD $0
Temporary Disability Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENT, CRITICAL ILLNESS, HOSPITAL, CANCER
Welfare Benefit Premiums Paid to CarrierUSD $21,222
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,453
Amount paid for insurance broker fees0
Insurance broker organization code?3
TRIAD RESOURCE GROUP, LLC DBA TRIAD EAP (National Association of Insurance Commissioners NAIC id number: 62419 )
Policy contract numberMF1
Policy instance 3
Insurance contract or identification numberMF1
Number of Individuals Covered192
Insurance policy start date2021-06-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedEMPLOYEE ASSISTANCE PROGRAM
Welfare Benefit Premiums Paid to CarrierUSD $11,615
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 numberGLUG0BCGG
Policy instance 4
Insurance contract or identification numberGLUG0BCGG
Number of Individuals Covered157
Insurance policy start date2021-06-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $1,115
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $7,812
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,115
Amount paid for insurance broker fees0
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLUG0BCGG
Policy instance 4
Insurance contract or identification numberGLUG0BCGG
Number of Individuals Covered158
Insurance policy start date2020-06-01
Insurance policy end date2021-05-31
Total amount of commissions paid to insurance brokerUSD $2,349
Total amount of fees paid to insurance companyUSD $987
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $16,299
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,349
Amount paid for insurance broker fees987
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
TRIAD RESOURCE GROUP, LLC DBA TRIAD EAP (National Association of Insurance Commissioners NAIC id number: 62419 )
Policy contract numberMF1
Policy instance 3
Insurance contract or identification numberMF1
Number of Individuals Covered180
Insurance policy start date2020-06-01
Insurance policy end date2021-05-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedEMPLOYEE ASSISTANCE PROGRAM
Welfare Benefit Premiums Paid to CarrierUSD $8,898
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )
Policy contract numberKHT14
Policy instance 2
Insurance contract or identification numberKHT14
Number of Individuals Covered53
Insurance policy start date2020-06-01
Insurance policy end date2021-05-31
Total amount of commissions paid to insurance brokerUSD $4,838
Total amount of fees paid to insurance companyUSD $164
Temporary Disability Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT, ACCIDENT, HOSPITAL, CANCER
Welfare Benefit Premiums Paid to CarrierUSD $50,653
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,570
Amount paid for insurance broker fees27
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number12065303
Policy instance 1
Insurance contract or identification number12065303
Number of Individuals Covered144
Insurance policy start date2020-06-01
Insurance policy end date2021-05-31
Total amount of commissions paid to insurance brokerUSD $1,240
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $24,458
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $686
Amount paid for insurance broker fees0
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLUG0BCGG
Policy instance 4
Insurance contract or identification numberGLUG0BCGG
Number of Individuals Covered149
Insurance policy start date2019-06-01
Insurance policy end date2020-05-31
Total amount of commissions paid to insurance brokerUSD $2,559
Total amount of fees paid to insurance companyUSD $1,303
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $17,725
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,559
Amount paid for insurance broker fees1303
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
TRIAD RESOURCE GROUP, LLC DBA TRIAD EAP (National Association of Insurance Commissioners NAIC id number: 62419 )
Policy contract numberMF1
Policy instance 3
Insurance contract or identification numberMF1
Number of Individuals Covered191
Insurance policy start date2019-06-01
Insurance policy end date2020-05-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedEMPLOYEE ASSISTANCE PROGRAM
Welfare Benefit Premiums Paid to CarrierUSD $9,548
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )
Policy contract numberKHT14
Policy instance 2
Insurance contract or identification numberKHT14
Number of Individuals Covered64
Insurance policy start date2019-06-01
Insurance policy end date2020-05-31
Total amount of commissions paid to insurance brokerUSD $8,489
Total amount of fees paid to insurance companyUSD $1,014
Temporary Disability Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT, ACCIDENT, HOSPITAL, CANCER
Welfare Benefit Premiums Paid to CarrierUSD $66,869
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,603
Amount paid for insurance broker fees428
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number12065303
Policy instance 1
Insurance contract or identification number12065303
Number of Individuals Covered136
Insurance policy start date2019-06-01
Insurance policy end date2020-05-31
Total amount of commissions paid to insurance brokerUSD $1,244
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $24,644
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,244
Amount paid for insurance broker fees0
Insurance broker organization code?3
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number12065303
Policy instance 1
Insurance contract or identification number12065303
Number of Individuals Covered154
Insurance policy start date2018-06-01
Insurance policy end date2019-05-31
Total amount of commissions paid to insurance brokerUSD $1,225
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $23,347
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,225
Amount paid for insurance broker fees0
Insurance broker organization code?3
TRIAD RESOURCE GROUP, LLC DBA TRIAD EAP (National Association of Insurance Commissioners NAIC id number: 62419 )
Policy contract numberMF1
Policy instance 3
Insurance contract or identification numberMF1
Number of Individuals Covered153
Insurance policy start date2018-06-01
Insurance policy end date2019-05-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedEMPLOYEE ASSISTANCE PROGRAM
Welfare Benefit Premiums Paid to CarrierUSD $6,184
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )
Policy contract numberKHT14
Policy instance 2
Insurance contract or identification numberKHT14
Number of Individuals Covered89
Insurance policy start date2018-06-01
Insurance policy end date2019-05-31
Total amount of commissions paid to insurance brokerUSD $18,129
Total amount of fees paid to insurance companyUSD $2,350
Temporary Disability Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT, ACCIDENT, HOSPITAL, CANCER
Welfare Benefit Premiums Paid to CarrierUSD $78,839
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,446
Amount paid for insurance broker fees988
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLUG0BCGG
Policy instance 4
Insurance contract or identification numberGLUG0BCGG
Number of Individuals Covered163
Insurance policy start date2018-06-01
Insurance policy end date2019-05-31
Total amount of commissions paid to insurance brokerUSD $2,174
Total amount of fees paid to insurance companyUSD $1,523
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $15,088
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,174
Amount paid for insurance broker fees1523
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )
Policy contract numberKHT14
Policy instance 3
Insurance contract or identification numberKHT14
Number of Individuals Covered88
Insurance policy start date2017-06-01
Insurance policy end date2018-05-31
Total amount of commissions paid to insurance brokerUSD $25,508
Total amount of fees paid to insurance companyUSD $488
Temporary Disability Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENT, CRITICAL ILLNESS, HOSPITAL
Welfare Benefit Premiums Paid to CarrierUSD $55,622
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $16,279
Amount paid for insurance broker fees465
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
Insurance broker nameANNETTTE S. WULFF AND OTHER AGENTS
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number12065303
Policy instance 2
Insurance contract or identification number12065303
Number of Individuals Covered138
Insurance policy start date2017-06-01
Insurance policy end date2018-05-31
Total amount of commissions paid to insurance brokerUSD $1,182
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $22,880
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,182
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameHUB INTERNATIONAL INS. SVCES., INC
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number423326
Policy instance 1
Insurance contract or identification number423326
Number of Individuals Covered145
Insurance policy start date2017-06-01
Insurance policy end date2018-05-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Life Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $11,436
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No

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