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SCHRYVER MEDICAL, LLC HEALTH AND WELFARE PLAN 401k Plan overview

Plan NameSCHRYVER MEDICAL, LLC HEALTH AND WELFARE PLAN
Plan identification number 501

SCHRYVER MEDICAL, LLC 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)
  • Long-term disability cover
  • Death benefits (include travel accident but not life insurance)
  • Other welfare benefit cover

401k Sponsoring company profile

SCHRYVER MEDICAL SALES AND MARKETING, LLC has sponsored the creation of one or more 401k plans.

Company Name:SCHRYVER MEDICAL SALES AND MARKETING, LLC
Employer identification number (EIN):841229620
NAIC Classification:621510
NAIC Description: Medical and Diagnostic Laboratories

Additional information about SCHRYVER MEDICAL SALES AND MARKETING, LLC

Jurisdiction of Incorporation: Colorado Department of State
Incorporation Date: 1993-04-15
Company Identification Number: 19931040124
Legal Registered Office Address: 12075 E 45TH AVE
SUITE 600
Denver
United States of America (USA)
80239

More information about SCHRYVER MEDICAL SALES AND MARKETING, LLC

Form 5500 Filing Information

Submission information for form 5500 for 401k plan SCHRYVER MEDICAL, LLC HEALTH AND WELFARE PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5012017-01-01
5012016-01-01
5012015-07-01RICH HEGSTAD RICH HEGSTAD2016-09-23
5012014-07-01RICH HEGSTAD RICH HEGSTAD2016-03-08
5012013-07-01RICH HEGSTAD
5012012-07-01JACK WHITE
5012011-07-01SUMMER KELLEY
5012009-07-01SUMMER KELLEY
5012009-04-01SUMMER KELLEY

Plan Statistics for SCHRYVER MEDICAL, LLC HEALTH AND WELFARE PLAN

401k plan membership statisitcs for SCHRYVER MEDICAL, LLC HEALTH AND WELFARE PLAN

Measure Date Value
2017: SCHRYVER MEDICAL, LLC HEALTH AND WELFARE PLAN 2017 401k membership
Total participants, beginning-of-year2017-01-011,117
Total number of active participants reported on line 7a of the Form 55002017-01-010
Number of retired or separated participants receiving benefits2017-01-010
Number of other retired or separated participants entitled to future benefits2017-01-010
Total of all active and inactive participants2017-01-010
2016: SCHRYVER MEDICAL, LLC HEALTH AND WELFARE PLAN 2016 401k membership
Total participants, beginning-of-year2016-01-01612
Total number of active participants reported on line 7a of the Form 55002016-01-011,095
Number of retired or separated participants receiving benefits2016-01-015
Number of other retired or separated participants entitled to future benefits2016-01-01108
Total of all active and inactive participants2016-01-011,208
2015: SCHRYVER MEDICAL, LLC HEALTH AND WELFARE PLAN 2015 401k membership
Total participants, beginning-of-year2015-07-01558
Total number of active participants reported on line 7a of the Form 55002015-07-01585
Number of retired or separated participants receiving benefits2015-07-016
Number of other retired or separated participants entitled to future benefits2015-07-0121
Total of all active and inactive participants2015-07-01612
2014: SCHRYVER MEDICAL, LLC HEALTH AND WELFARE PLAN 2014 401k membership
Total participants, beginning-of-year2014-07-01422
Total number of active participants reported on line 7a of the Form 55002014-07-01558
Number of retired or separated participants receiving benefits2014-07-010
Number of other retired or separated participants entitled to future benefits2014-07-010
Total of all active and inactive participants2014-07-01558
2013: SCHRYVER MEDICAL, LLC HEALTH AND WELFARE PLAN 2013 401k membership
Total participants, beginning-of-year2013-07-01382
Total number of active participants reported on line 7a of the Form 55002013-07-01421
Number of retired or separated participants receiving benefits2013-07-011
Number of other retired or separated participants entitled to future benefits2013-07-010
Total of all active and inactive participants2013-07-01422
2012: SCHRYVER MEDICAL, LLC HEALTH AND WELFARE PLAN 2012 401k membership
Total participants, beginning-of-year2012-07-01333
Total number of active participants reported on line 7a of the Form 55002012-07-01382
Number of retired or separated participants receiving benefits2012-07-011
Number of other retired or separated participants entitled to future benefits2012-07-010
Total of all active and inactive participants2012-07-01383
2011: SCHRYVER MEDICAL, LLC HEALTH AND WELFARE PLAN 2011 401k membership
Total participants, beginning-of-year2011-07-01413
Total number of active participants reported on line 7a of the Form 55002011-07-01463
Number of retired or separated participants receiving benefits2011-07-0123
Number of other retired or separated participants entitled to future benefits2011-07-010
Total of all active and inactive participants2011-07-01486
2009: SCHRYVER MEDICAL, LLC HEALTH AND WELFARE PLAN 2009 401k membership
Total participants, beginning-of-year2009-07-01350
Total number of active participants reported on line 7a of the Form 55002009-07-01378
Number of retired or separated participants receiving benefits2009-07-013
Number of other retired or separated participants entitled to future benefits2009-07-010
Total of all active and inactive participants2009-07-01381
Total participants, beginning-of-year2009-04-01332
Total number of active participants reported on line 7a of the Form 55002009-04-01348
Number of retired or separated participants receiving benefits2009-04-012
Number of other retired or separated participants entitled to future benefits2009-04-010
Total of all active and inactive participants2009-04-01350
Total participants2009-04-01350

Form 5500 Responses for SCHRYVER MEDICAL, LLC HEALTH AND WELFARE PLAN

2017: SCHRYVER MEDICAL, LLC HEALTH AND WELFARE PLAN 2017 form 5500 responses
2017-01-01Type of plan entitySingle employer plan
2017-01-01This submission is the final filingYes
2017-01-01Plan funding arrangement – InsuranceYes
2017-01-01Plan funding arrangement – General assets of the sponsorYes
2017-01-01Plan benefit arrangement – InsuranceYes
2017-01-01Plan benefit arrangement – General assets of the sponsorYes
2016: SCHRYVER MEDICAL, LLC HEALTH AND WELFARE PLAN 2016 form 5500 responses
2016-01-01Type of plan entitySingle employer plan
2016-01-01Submission has been amendedNo
2016-01-01This submission is the final filingNo
2016-01-01This return/report is a short plan year return/report (less than 12 months)No
2016-01-01Plan is a collectively bargained planNo
2016-01-01Plan funding arrangement – InsuranceYes
2016-01-01Plan funding arrangement – General assets of the sponsorYes
2016-01-01Plan benefit arrangement – InsuranceYes
2016-01-01Plan benefit arrangement – General assets of the sponsorYes
2015: SCHRYVER MEDICAL, LLC HEALTH AND WELFARE PLAN 2015 form 5500 responses
2015-07-01Type of plan entitySingle employer plan
2015-07-01Submission has been amendedNo
2015-07-01This submission is the final filingNo
2015-07-01This return/report is a short plan year return/report (less than 12 months)Yes
2015-07-01Plan is a collectively bargained planNo
2015-07-01Plan funding arrangement – InsuranceYes
2015-07-01Plan funding arrangement – General assets of the sponsorYes
2015-07-01Plan benefit arrangement – InsuranceYes
2015-07-01Plan benefit arrangement – General assets of the sponsorYes
2014: SCHRYVER MEDICAL, LLC HEALTH AND WELFARE PLAN 2014 form 5500 responses
2014-07-01Type of plan entitySingle employer plan
2014-07-01Submission has been amendedNo
2014-07-01This submission is the final filingNo
2014-07-01This return/report is a short plan year return/report (less than 12 months)No
2014-07-01Plan is a collectively bargained planNo
2014-07-01Plan funding arrangement – InsuranceYes
2014-07-01Plan funding arrangement – General assets of the sponsorYes
2014-07-01Plan benefit arrangement – InsuranceYes
2014-07-01Plan benefit arrangement – General assets of the sponsorYes
2013: SCHRYVER MEDICAL, LLC HEALTH AND WELFARE PLAN 2013 form 5500 responses
2013-07-01Type of plan entitySingle employer plan
2013-07-01Submission has been amendedNo
2013-07-01This submission is the final filingNo
2013-07-01This return/report is a short plan year return/report (less than 12 months)No
2013-07-01Plan is a collectively bargained planNo
2013-07-01Plan funding arrangement – InsuranceYes
2013-07-01Plan funding arrangement – General assets of the sponsorYes
2013-07-01Plan benefit arrangement – InsuranceYes
2013-07-01Plan benefit arrangement – General assets of the sponsorYes
2012: SCHRYVER MEDICAL, LLC HEALTH AND WELFARE PLAN 2012 form 5500 responses
2012-07-01Type of plan entitySingle employer plan
2012-07-01Submission has been amendedNo
2012-07-01This submission is the final filingNo
2012-07-01This return/report is a short plan year return/report (less than 12 months)No
2012-07-01Plan is a collectively bargained planNo
2012-07-01Plan funding arrangement – InsuranceYes
2012-07-01Plan benefit arrangement – InsuranceYes
2011: SCHRYVER MEDICAL, LLC HEALTH AND WELFARE PLAN 2011 form 5500 responses
2011-07-01Type of plan entitySingle employer plan
2011-07-01Submission has been amendedNo
2011-07-01This submission is the final filingNo
2011-07-01This return/report is a short plan year return/report (less than 12 months)No
2011-07-01Plan is a collectively bargained planNo
2011-07-01Plan funding arrangement – InsuranceYes
2011-07-01Plan benefit arrangement – InsuranceYes
2009: SCHRYVER MEDICAL, LLC HEALTH AND WELFARE PLAN 2009 form 5500 responses
2009-07-01Type of plan entitySingle employer plan
2009-07-01Submission has been amendedNo
2009-07-01This submission is the final filingNo
2009-07-01This return/report is a short plan year return/report (less than 12 months)No
2009-07-01Plan is a collectively bargained planNo
2009-07-01Plan funding arrangement – InsuranceYes
2009-07-01Plan benefit arrangement – InsuranceYes
2009-04-01Type of plan entitySingle employer plan
2009-04-01Submission has been amendedNo
2009-04-01This submission is the final filingNo
2009-04-01This return/report is a short plan year return/report (less than 12 months)Yes
2009-04-01Plan is a collectively bargained planNo
2009-04-01Plan funding arrangement – InsuranceYes
2009-04-01Plan benefit arrangement – InsuranceYes

Insurance Providers Used on plan

DELTA DENTAL OF COLORADO (National Association of Insurance Commissioners NAIC id number: 55875 )
Policy contract number8127
Policy instance 3
Insurance contract or identification number8127
Number of Individuals Covered1065
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Welfare Benefit Premiums Paid to CarrierUSD $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number909501
Policy instance 2
Insurance contract or identification number909501
Number of Individuals Covered1065
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $25,033
Total amount of fees paid to insurance companyUSD $12,517
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT, EMPLOYEE ASSISTANCE PROGRAM
Welfare Benefit Premiums Paid to CarrierUSD $250,328
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $25,033
Amount paid for insurance broker fees12517
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
Insurance broker organization code?3
Insurance broker nameLOCKTON COMPANIES, LLC
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number0905252
Policy instance 1
Insurance contract or identification number0905252
Number of Individuals Covered946
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $148,919
Total amount of fees paid to insurance companyUSD $51,379
Health Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $4,816,589
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $148,919
Amount paid for insurance broker fees51379
Additional information about fees paid to insurance brokerBONUS
Insurance broker organization code?3
Insurance broker nameLOCKTON COMPANIES, LLC
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number905252
Policy instance 3
Insurance contract or identification number905252
Number of Individuals Covered523
Insurance policy start date2015-07-01
Insurance policy end date2015-12-31
Total amount of commissions paid to insurance brokerUSD $29,127
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $1,137,371
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $29,127
Insurance broker organization code?3
Insurance broker nameLOCKTON COMPANIES, LLC
RELIASTAR LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 67105 )
Policy contract number68919-0
Policy instance 2
Insurance contract or identification number68919-0
Number of Individuals Covered585
Insurance policy start date2015-07-01
Insurance policy end date2015-12-31
Total amount of commissions paid to insurance brokerUSD $5,789
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT EMPLOYEE ASSISTANCE PROGRAM
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 CarrierUSD $59,382
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,789
Insurance broker organization code?3
Insurance broker nameLOCKTON COMPANIES, LLC
DELTA DENTAL OF COLORADO (National Association of Insurance Commissioners NAIC id number: 55875 )
Policy contract number8127/8128
Policy instance 1
Insurance contract or identification number8127/8128
Number of Individuals Covered526
Insurance policy start date2015-07-01
Insurance policy end date2015-12-31
Total amount of commissions paid to insurance brokerUSD $5,811
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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
Commission paid to Insurance BrokerUSD $5,811
Insurance broker organization code?3
Insurance broker nameLOCKTON COMPANIES, LLC
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number30002965
Policy instance 3
Insurance contract or identification number30002965
Number of Individuals Covered206
Insurance policy start date2014-07-01
Insurance policy end date2015-06-30
Total amount of commissions paid to insurance brokerUSD $2,403
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $24,037
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,209
Insurance broker organization code?3
Insurance broker nameLOCKTON COMPANIES, LLC
KANAWHA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65110 )
Policy contract number650301
Policy instance 4
Insurance contract or identification number650301
Number of Individuals Covered449
Insurance policy start date2014-07-01
Insurance policy end date2015-06-30
Total amount of commissions paid to insurance brokerUSD $9,031
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND 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 CarrierUSD $86,500
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,658
Insurance broker organization code?3
Insurance broker nameVAN GILDER INSURANCE CORPORATION
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number847019
Policy instance 1
Insurance contract or identification number847019
Number of Individuals Covered388
Insurance policy start date2014-07-01
Insurance policy end date2015-06-30
Total amount of commissions paid to insurance brokerUSD $53,256
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $1,782,905
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $26,922
Insurance broker organization code?3
Insurance broker nameSHIRAZI BENEFITS, LLC
DELTA DENTAL OF COLORADO (National Association of Insurance Commissioners NAIC id number: 55875 )
Policy contract number8127/8128
Policy instance 2
Insurance contract or identification number8127/8128
Number of Individuals Covered431
Insurance policy start date2014-07-01
Insurance policy end date2015-06-30
Total amount of commissions paid to insurance brokerUSD $14,987
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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
Commission paid to Insurance BrokerUSD $7,514
Insurance broker organization code?3
Insurance broker nameUSI INSURANCE SERVICES, LLC
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number847019
Policy instance 1
Insurance contract or identification number847019
Number of Individuals Covered364
Insurance policy start date2013-07-01
Insurance policy end date2014-06-30
Total amount of commissions paid to insurance brokerUSD $55,299
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $1,812,172
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $41,862
Insurance broker organization code?3
Insurance broker nameUSI INSURANCE SERVICES, LLC
DELTA DENTAL OF COLORADO (National Association of Insurance Commissioners NAIC id number: 55875 )
Policy contract number8127/8128
Policy instance 2
Insurance contract or identification number8127/8128
Number of Individuals Covered435
Insurance policy start date2013-07-01
Insurance policy end date2014-06-30
Total amount of commissions paid to insurance brokerUSD $13,608
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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
Commission paid to Insurance BrokerUSD $12,481
Insurance broker organization code?3
Insurance broker nameSHIRAZI BENEFITS, LLC
KANAWHA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65110 )
Policy contract number650301
Policy instance 4
Insurance contract or identification number650301
Number of Individuals Covered428
Insurance policy start date2013-07-01
Insurance policy end date2014-06-30
Total amount of commissions paid to insurance brokerUSD $8,874
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND 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 CarrierUSD $76,170
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $7,732
Insurance broker organization code?3
Insurance broker nameSHIRAZI BENEFITS, LLC
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number30002965
Policy instance 3
Insurance contract or identification number30002965
Number of Individuals Covered205
Insurance policy start date2013-07-01
Insurance policy end date2014-06-30
Total amount of commissions paid to insurance brokerUSD $2,389
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $23,884
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,993
Insurance broker organization code?3
Insurance broker nameSHIRAZI BENEFITS, LLC
DELTA DENTAL OF COLORADO (National Association of Insurance Commissioners NAIC id number: 55875 )
Policy contract number8128
Policy instance 2
Insurance contract or identification number8128
Number of Individuals Covered76
Insurance policy start date2012-07-01
Insurance policy end date2013-06-30
Total amount of commissions paid to insurance brokerUSD $3,368
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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
Commission paid to Insurance BrokerUSD $3,368
Insurance broker organization code?3
Insurance broker nameVAN GILDER INSURANCE CORP
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number847019
Policy instance 3
Insurance contract or identification number847019
Number of Individuals Covered382
Insurance policy start date2012-07-01
Insurance policy end date2013-06-30
Total amount of commissions paid to insurance brokerUSD $64,423
Total amount of fees paid to insurance companyUSD $15,000
Are there contracts with allocated funds for individual policies?No
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $1,748,220
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $64,423
Amount paid for insurance broker fees15000
Additional information about fees paid to insurance broker2012 MEDICAL NEW BUSINESS SUPPLEMENTAL COMPENSATION
Insurance broker organization code?3
Insurance broker nameVAN GILDER INSURANCE CORP
DELTA DENTAL OF COLORADO (National Association of Insurance Commissioners NAIC id number: 55875 )
Policy contract number8127
Policy instance 1
Insurance contract or identification number8127
Number of Individuals Covered392
Insurance policy start date2012-07-01
Insurance policy end date2013-06-30
Total amount of commissions paid to insurance brokerUSD $9,884
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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
Commission paid to Insurance BrokerUSD $9,884
Insurance broker organization code?3
Insurance broker nameVAN GILDER INSURANCE CORP
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number30002965
Policy instance 5
Insurance contract or identification number30002965
Number of Individuals Covered189
Insurance policy start date2012-07-01
Insurance policy end date2013-06-30
Total amount of commissions paid to insurance brokerUSD $2,545
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $25,453
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,545
Insurance broker organization code?3
Insurance broker nameVAN GILDER INSURANCE CORP
KANAWHA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65110 )
Policy contract numberK100962
Policy instance 4
Insurance contract or identification numberK100962
Number of Individuals Covered397
Insurance policy start date2012-07-01
Insurance policy end date2013-06-30
Total amount of commissions paid to insurance brokerUSD $12,359
Total amount of fees paid to insurance companyUSD $182
Are there contracts with allocated funds for individual policies?No
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 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 & 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 CarrierUSD $76,327
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $12,359
Amount paid for insurance broker fees182
Additional information about fees paid to insurance brokerVOLUME INCENTIVES
Insurance broker organization code?3
Insurance broker nameVAN GILDER INSURANCE CORP
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number0713993
Policy instance 3
Insurance contract or identification number0713993
Number of Individuals Covered411
Insurance policy start date2011-07-01
Insurance policy end date2012-06-30
Total amount of commissions paid to insurance brokerUSD $63,825
Total amount of fees paid to insurance companyUSD $4,245
Are there contracts with allocated funds for individual policies?No
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $1,741,624
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 number30002965
Policy instance 5
Insurance contract or identification number30002965
Number of Individuals Covered216
Insurance policy start date2011-07-01
Insurance policy end date2012-06-30
Total amount of commissions paid to insurance brokerUSD $2,682
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $26,816
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 number8127
Policy instance 1
Insurance contract or identification number8127
Number of Individuals Covered434
Insurance policy start date2011-07-01
Insurance policy end date2012-06-30
Total amount of commissions paid to insurance brokerUSD $9,800
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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
DELTA DENTAL OF COLORADO (National Association of Insurance Commissioners NAIC id number: 55875 )
Policy contract number8128
Policy instance 2
Insurance contract or identification number8128
Number of Individuals Covered96
Insurance policy start date2011-07-01
Insurance policy end date2012-06-30
Total amount of commissions paid to insurance brokerUSD $3,440
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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
KANAWHA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65110 )
Policy contract numberK100962
Policy instance 4
Insurance contract or identification numberK100962
Number of Individuals Covered463
Insurance policy start date2011-07-01
Insurance policy end date2012-06-30
Total amount of commissions paid to insurance brokerUSD $11,083
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 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 & 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 CarrierUSD $72,011
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 number8127
Policy instance 1
Insurance contract or identification number8127
Number of Individuals Covered419
Insurance policy start date2010-07-01
Insurance policy end date2011-06-30
Total amount of commissions paid to insurance brokerUSD $8,787
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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: 39616 )
Policy contract number30002965
Policy instance 5
Insurance contract or identification number30002965
Number of Individuals Covered205
Insurance policy start date2010-07-01
Insurance policy end date2011-06-30
Total amount of commissions paid to insurance brokerUSD $2,366
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $23,654
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number301339
Policy instance 4
Insurance contract or identification number301339
Number of Individuals Covered413
Insurance policy start date2010-07-01
Insurance policy end date2011-06-30
Total amount of commissions paid to insurance brokerUSD $1,539
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 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 & 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 CarrierUSD $17,084
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number0713993
Policy instance 3
Insurance contract or identification number0713993
Number of Individuals Covered383
Insurance policy start date2010-07-01
Insurance policy end date2011-06-30
Total amount of commissions paid to insurance brokerUSD $60,732
Total amount of fees paid to insurance companyUSD $4,155
Are there contracts with allocated funds for individual policies?No
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $1,518,307
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 number8128
Policy instance 2
Insurance contract or identification number8128
Number of Individuals Covered73
Insurance policy start date2010-07-01
Insurance policy end date2011-06-30
Total amount of commissions paid to insurance brokerUSD $1,957
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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

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