ICI BENEFITS CONSORTIUM has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan ICI BENEFITS CONSORTIUM HEALTH PLAN
| Measure | Date | Value |
|---|
| 2022 : ICI BENEFITS CONSORTIUM HEALTH PLAN 2022 401k financial data |
|---|
| Total unrealized appreciation/depreciation of assets | 2022-12-31 | $0 |
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2022-12-31 | $2,004,772 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2022-12-31 | $2,001,368 |
| Total income from all sources (including contributions) | 2022-12-31 | $11,126,910 |
| Total loss/gain on sale of assets | 2022-12-31 | $0 |
| Total of all expenses incurred | 2022-12-31 | $9,345,127 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2022-12-31 | $8,629,296 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2022-12-31 | $11,097,455 |
| Value of total assets at end of year | 2022-12-31 | $7,390,160 |
| Value of total assets at beginning of year | 2022-12-31 | $5,604,973 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2022-12-31 | $715,831 |
| Total interest from all sources | 2022-12-31 | $29,455 |
| Total dividends received (eg from common stock, registered investment company shares) | 2022-12-31 | $0 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2022-12-31 | No |
| Administrative expenses professional fees incurred | 2022-12-31 | $715,831 |
| Was this plan covered by a fidelity bond | 2022-12-31 | Yes |
| Value of fidelity bond cover | 2022-12-31 | $500,000 |
| 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 |
| Contributions received from participants | 2022-12-31 | $26,430 |
| Value of other receiveables (less allowance for doubtful accounts) at end of year | 2022-12-31 | $2,676,546 |
| Value of other receiveables (less allowance for doubtful accounts) at beginning of year | 2022-12-31 | $757,629 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year | 2022-12-31 | $0 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year | 2022-12-31 | $457,805 |
| Liabilities. Value of operating payables at end of year | 2022-12-31 | $5,051 |
| Liabilities. Value of operating payables at beginning of year | 2022-12-31 | $2,950 |
| 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 | $1,781,783 |
| Value of net assets at end of year (total assets less liabilities) | 2022-12-31 | $5,385,388 |
| Value of net assets at beginning of year (total assets less liabilities) | 2022-12-31 | $3,603,605 |
| 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 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year | 2022-12-31 | $4,713,614 |
| Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year | 2022-12-31 | $4,847,344 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year | 2022-12-31 | $4,847,344 |
| Interest earned from interest bearing cash (including money market accounts and certificates of deposit) | 2022-12-31 | $29,455 |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2022-12-31 | $1,516,686 |
| 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 | $11,071,025 |
| Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers | 2022-12-31 | $7,112,610 |
| Liabilities. Value of benefit claims payable at end of year | 2022-12-31 | $1,999,721 |
| Liabilities. Value of benefit claims payable at beginning of year | 2022-12-31 | $1,540,613 |
| Did the plan have assets held for investment | 2022-12-31 | Yes |
| 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 |
| Opinion of an independent qualified public accountant for this plan | 2022-12-31 | Unqualified |
| Accountancy firm name | 2022-12-31 | BRADYWARE & SCHOENFELD |
| Accountancy firm EIN | 2022-12-31 | 351476702 |
| 2021 : ICI BENEFITS CONSORTIUM HEALTH PLAN 2021 401k financial data |
|---|
| Total unrealized appreciation/depreciation of assets | 2021-12-31 | $0 |
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2021-12-31 | $2,001,368 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2021-12-31 | $1,650,622 |
| Total income from all sources (including contributions) | 2021-12-31 | $10,955,240 |
| Total loss/gain on sale of assets | 2021-12-31 | $0 |
| Total of all expenses incurred | 2021-12-31 | $8,822,392 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2021-12-31 | $8,131,660 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2021-12-31 | $10,954,763 |
| Value of total assets at end of year | 2021-12-31 | $5,604,973 |
| Value of total assets at beginning of year | 2021-12-31 | $3,121,379 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2021-12-31 | $690,732 |
| Total interest from all sources | 2021-12-31 | $477 |
| Total dividends received (eg from common stock, registered investment company shares) | 2021-12-31 | $0 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2021-12-31 | No |
| Administrative expenses professional fees incurred | 2021-12-31 | $690,732 |
| Was this plan covered by a fidelity bond | 2021-12-31 | Yes |
| Value of fidelity bond cover | 2021-12-31 | $500,000 |
| 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 |
| Contributions received from participants | 2021-12-31 | $68,100 |
| Value of other receiveables (less allowance for doubtful accounts) at end of year | 2021-12-31 | $757,629 |
| Value of other receiveables (less allowance for doubtful accounts) at beginning of year | 2021-12-31 | $318,612 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year | 2021-12-31 | $457,805 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year | 2021-12-31 | $34,113 |
| Liabilities. Value of operating payables at end of year | 2021-12-31 | $2,950 |
| Liabilities. Value of operating payables at beginning of year | 2021-12-31 | $2,200 |
| 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 | $2,132,848 |
| Value of net assets at end of year (total assets less liabilities) | 2021-12-31 | $3,603,605 |
| Value of net assets at beginning of year (total assets less liabilities) | 2021-12-31 | $1,470,757 |
| 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 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year | 2021-12-31 | $4,847,344 |
| Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year | 2021-12-31 | $2,802,767 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year | 2021-12-31 | $2,802,767 |
| Interest earned from interest bearing cash (including money market accounts and certificates of deposit) | 2021-12-31 | $477 |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2021-12-31 | $1,347,664 |
| 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 | $10,886,663 |
| Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers | 2021-12-31 | $6,783,996 |
| Liabilities. Value of benefit claims payable at end of year | 2021-12-31 | $1,540,613 |
| Liabilities. Value of benefit claims payable at beginning of year | 2021-12-31 | $1,614,309 |
| 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 |
| Opinion of an independent qualified public accountant for this plan | 2021-12-31 | Unqualified |
| Accountancy firm name | 2021-12-31 | BRADYWARE & SCHOENFELD |
| Accountancy firm EIN | 2021-12-31 | 351476702 |
| 2020 : ICI BENEFITS CONSORTIUM HEALTH PLAN 2020 401k financial data |
|---|
| Total unrealized appreciation/depreciation of assets | 2020-12-31 | $0 |
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2020-12-31 | $1,650,622 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2020-12-31 | $426,551 |
| Total income from all sources (including contributions) | 2020-12-31 | $10,776,052 |
| Total loss/gain on sale of assets | 2020-12-31 | $0 |
| Total of all expenses incurred | 2020-12-31 | $9,805,432 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2020-12-31 | $9,215,693 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2020-12-31 | $10,775,182 |
| Value of total assets at end of year | 2020-12-31 | $3,121,379 |
| Value of total assets at beginning of year | 2020-12-31 | $926,688 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2020-12-31 | $589,739 |
| Total interest from all sources | 2020-12-31 | $870 |
| Total dividends received (eg from common stock, registered investment company shares) | 2020-12-31 | $0 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2020-12-31 | No |
| Administrative expenses professional fees incurred | 2020-12-31 | $589,739 |
| Was this plan covered by a fidelity bond | 2020-12-31 | Yes |
| Value of fidelity bond cover | 2020-12-31 | $500,000 |
| 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 |
| Contributions received from participants | 2020-12-31 | $45,598 |
| Value of other receiveables (less allowance for doubtful accounts) at end of year | 2020-12-31 | $318,612 |
| Value of other receiveables (less allowance for doubtful accounts) at beginning of year | 2020-12-31 | $121,247 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year | 2020-12-31 | $34,113 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year | 2020-12-31 | $426,551 |
| Liabilities. Value of operating payables at end of year | 2020-12-31 | $2,200 |
| 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 | $970,620 |
| Value of net assets at end of year (total assets less liabilities) | 2020-12-31 | $1,470,757 |
| Value of net assets at beginning of year (total assets less liabilities) | 2020-12-31 | $500,137 |
| 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 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year | 2020-12-31 | $2,802,767 |
| Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year | 2020-12-31 | $805,441 |
| Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year | 2020-12-31 | $805,441 |
| Interest earned from interest bearing cash (including money market accounts and certificates of deposit) | 2020-12-31 | $870 |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2020-12-31 | $1,360,379 |
| 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 | $10,729,584 |
| Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers | 2020-12-31 | $7,855,314 |
| Liabilities. Value of benefit claims payable at end of year | 2020-12-31 | $1,614,309 |
| 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 |
| Opinion of an independent qualified public accountant for this plan | 2020-12-31 | Unqualified |
| Accountancy firm name | 2020-12-31 | BRADYWARE & SCHOENFELD |
| Accountancy firm EIN | 2020-12-31 | 351476702 |
| RXBENEFITS (National Association of Insurance Commissioners NAIC id number: 52429 ) |
| Policy contract number | HUNTINGTON |
| Policy instance | 7 |
| Insurance contract or identification number | HUNTINGTON | | Number of Individuals Covered | 149 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $0 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| RXBENEFITS (National Association of Insurance Commissioners NAIC id number: 52429 ) |
| Policy contract number | HANOVER |
| Policy instance | 6 |
| Insurance contract or identification number | HANOVER | | Number of Individuals Covered | 213 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $0 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| RXBENEFITS (National Association of Insurance Commissioners NAIC id number: 52429 ) |
| Policy contract number | MARTIN |
| Policy instance | 5 |
| Insurance contract or identification number | MARTIN | | Number of Individuals Covered | 34 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $0 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| RXBENEFITS (National Association of Insurance Commissioners NAIC id number: 52429 ) |
| Policy contract number | OAKLAND CITY |
| Policy instance | 4 |
| Insurance contract or identification number | OAKLAND CITY | | Number of Individuals Covered | 61 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $0 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| DELTA DENTAL OF INDIANA (National Association of Insurance Commissioners NAIC id number: 52634 ) |
| Policy contract number | 10118 |
| Policy instance | 3 |
| Insurance contract or identification number | 10118 | | Number of Individuals Covered | 1301 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $34,069 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $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 $34,069 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | NA | | Insurance broker organization code? | 3 |
|
| RXBENEFITS (National Association of Insurance Commissioners NAIC id number: 52429 ) |
| Policy contract number | EARLHAM |
| Policy instance | 2 |
| Insurance contract or identification number | EARLHAM | | Number of Individuals Covered | 282 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $0 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| SYMETRA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68608 ) |
| Policy contract number | 417008414196 |
| Policy instance | 1 |
| Insurance contract or identification number | 417008414196 | | Number of Individuals Covered | 740 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $1,516,590 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| DELTA DENTAL OF INDIANA (National Association of Insurance Commissioners NAIC id number: 52634 ) |
| Policy contract number | 10118 |
| Policy instance | 2 |
| Insurance contract or identification number | 10118 | | Number of Individuals Covered | 491 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $29,637 | | Total amount of fees paid to insurance company | USD $10,320 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Commission paid to Insurance Broker | USD $29,637 | | Amount paid for insurance broker fees | 10320 | | Additional information about fees paid to insurance broker | NEW BUSINESS BONUS | | Insurance broker organization code? | 3 |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 417006414196 |
| Policy instance | 1 |
| Insurance contract or identification number | 417006414196 | | Number of Individuals Covered | 752 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $1,347,506 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 417006414196 |
| Policy instance | 1 |
| Insurance contract or identification number | 417006414196 | | Number of Individuals Covered | 777 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $1,360,379 |
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