PSA BEHAVIORAL HEALTH AGENCY DBA RESILIENT HEALTH has sponsored the creation of one or more 401k plans.
Measure | Date | Value |
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2022: PSA BEHAVIORAL HEALTH AGENCY 2022 401k membership |
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Total participants, beginning-of-year | 2022-01-01 | 135 |
Total number of active participants reported on line 7a of the Form 5500 | 2022-01-01 | 143 |
Number of retired or separated participants receiving benefits | 2022-01-01 | 0 |
Number of other retired or separated participants entitled to future benefits | 2022-01-01 | 0 |
Total of all active and inactive participants | 2022-01-01 | 143 |
Number of employers contributing to the scheme | 2022-01-01 | 0 |
2021: PSA BEHAVIORAL HEALTH AGENCY 2021 401k membership |
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Total participants, beginning-of-year | 2021-01-01 | 151 |
Total number of active participants reported on line 7a of the Form 5500 | 2021-01-01 | 135 |
Number of retired or separated participants receiving benefits | 2021-01-01 | 0 |
Number of other retired or separated participants entitled to future benefits | 2021-01-01 | 0 |
Total of all active and inactive participants | 2021-01-01 | 135 |
Number of employers contributing to the scheme | 2021-01-01 | 0 |
2020: PSA BEHAVIORAL HEALTH AGENCY 2020 401k membership |
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Total participants, beginning-of-year | 2020-01-01 | 180 |
Total number of active participants reported on line 7a of the Form 5500 | 2020-01-01 | 151 |
Number of retired or separated participants receiving benefits | 2020-01-01 | 0 |
Number of other retired or separated participants entitled to future benefits | 2020-01-01 | 0 |
Total of all active and inactive participants | 2020-01-01 | 151 |
Number of employers contributing to the scheme | 2020-01-01 | 0 |
2019: PSA BEHAVIORAL HEALTH AGENCY 2019 401k membership |
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Total participants, beginning-of-year | 2019-01-01 | 268 |
Total number of active participants reported on line 7a of the Form 5500 | 2019-01-01 | 148 |
Number of retired or separated participants receiving benefits | 2019-01-01 | 0 |
Number of other retired or separated participants entitled to future benefits | 2019-01-01 | 0 |
Total of all active and inactive participants | 2019-01-01 | 148 |
Number of employers contributing to the scheme | 2019-01-01 | 0 |
2018: PSA BEHAVIORAL HEALTH AGENCY 2018 401k membership |
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Total participants, beginning-of-year | 2018-01-01 | 180 |
Total number of active participants reported on line 7a of the Form 5500 | 2018-01-01 | 196 |
Number of retired or separated participants receiving benefits | 2018-01-01 | 1 |
Number of other retired or separated participants entitled to future benefits | 2018-01-01 | 0 |
Total of all active and inactive participants | 2018-01-01 | 197 |
2017: PSA BEHAVIORAL HEALTH AGENCY 2017 401k membership |
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Total participants, beginning-of-year | 2017-01-01 | 158 |
Total number of active participants reported on line 7a of the Form 5500 | 2017-01-01 | 180 |
Total of all active and inactive participants | 2017-01-01 | 180 |
Total participants | 2017-01-01 | 180 |
2016: PSA BEHAVIORAL HEALTH AGENCY 2016 401k membership |
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Total participants, beginning-of-year | 2016-01-01 | 152 |
Total number of active participants reported on line 7a of the Form 5500 | 2016-01-01 | 158 |
Total of all active and inactive participants | 2016-01-01 | 158 |
Total participants | 2016-01-01 | 158 |
2015: PSA BEHAVIORAL HEALTH AGENCY 2015 401k membership |
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Total participants, beginning-of-year | 2015-01-01 | 108 |
Total number of active participants reported on line 7a of the Form 5500 | 2015-01-01 | 149 |
Number of retired or separated participants receiving benefits | 2015-01-01 | 3 |
Number of other retired or separated participants entitled to future benefits | 2015-01-01 | 0 |
Total of all active and inactive participants | 2015-01-01 | 152 |
2014: PSA BEHAVIORAL HEALTH AGENCY 2014 401k membership |
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Total participants, beginning-of-year | 2014-12-01 | 87 |
Total number of active participants reported on line 7a of the Form 5500 | 2014-12-01 | 87 |
Total of all active and inactive participants | 2014-12-01 | 87 |
Total participants | 2014-12-01 | 87 |
Total participants, beginning-of-year | 2014-01-01 | 137 |
Total number of active participants reported on line 7a of the Form 5500 | 2014-01-01 | 159 |
Total of all active and inactive participants | 2014-01-01 | 159 |
Total participants | 2014-01-01 | 159 |
2013: PSA BEHAVIORAL HEALTH AGENCY 2013 401k membership |
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Total participants, beginning-of-year | 2013-10-01 | 123 |
Total number of active participants reported on line 7a of the Form 5500 | 2013-10-01 | 137 |
Total of all active and inactive participants | 2013-10-01 | 137 |
Total participants | 2013-10-01 | 137 |
2012: PSA BEHAVIORAL HEALTH AGENCY 2012 401k membership |
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Total participants, beginning-of-year | 2012-10-01 | 97 |
Total number of active participants reported on line 7a of the Form 5500 | 2012-10-01 | 123 |
Total of all active and inactive participants | 2012-10-01 | 123 |
Total participants | 2012-10-01 | 123 |
2022: PSA BEHAVIORAL HEALTH AGENCY 2022 form 5500 responses |
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2022-01-01 | Type of plan entity | Single employer plan |
2022-01-01 | Plan funding arrangement – Insurance | Yes |
2022-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2022-01-01 | Plan benefit arrangement – Insurance | Yes |
2022-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
2021: PSA BEHAVIORAL HEALTH AGENCY 2021 form 5500 responses |
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2021-01-01 | Type of plan entity | Single employer plan |
2021-01-01 | Plan funding arrangement – Insurance | Yes |
2021-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2021-01-01 | Plan benefit arrangement – Insurance | Yes |
2021-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
2020: PSA BEHAVIORAL HEALTH AGENCY 2020 form 5500 responses |
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2020-01-01 | Type of plan entity | Single employer plan |
2020-01-01 | Plan funding arrangement – Insurance | Yes |
2020-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2020-01-01 | Plan benefit arrangement – Insurance | Yes |
2020-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
2019: PSA BEHAVIORAL HEALTH AGENCY 2019 form 5500 responses |
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2019-01-01 | Type of plan entity | Single employer plan |
2019-01-01 | Plan funding arrangement – Insurance | Yes |
2019-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2019-01-01 | Plan benefit arrangement – Insurance | Yes |
2019-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
2018: PSA BEHAVIORAL HEALTH AGENCY 2018 form 5500 responses |
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2018-01-01 | Type of plan entity | Single employer plan |
2018-01-01 | Submission has been amended | No |
2018-01-01 | This submission is the final filing | No |
2018-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2018-01-01 | Plan is a collectively bargained plan | No |
2018-01-01 | Plan funding arrangement – Insurance | Yes |
2018-01-01 | Plan benefit arrangement – Insurance | Yes |
2017: PSA BEHAVIORAL HEALTH AGENCY 2017 form 5500 responses |
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2017-01-01 | Type of plan entity | Single employer plan |
2017-01-01 | Submission has been amended | No |
2017-01-01 | This submission is the final filing | No |
2017-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2017-01-01 | Plan is a collectively bargained plan | No |
2017-01-01 | Plan funding arrangement – Insurance | Yes |
2017-01-01 | Plan benefit arrangement – Insurance | Yes |
2016: PSA BEHAVIORAL HEALTH AGENCY 2016 form 5500 responses |
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2016-01-01 | Type of plan entity | Single employer plan |
2016-01-01 | Submission has been amended | No |
2016-01-01 | This submission is the final filing | No |
2016-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2016-01-01 | Plan is a collectively bargained plan | No |
2016-01-01 | Plan funding arrangement – Insurance | Yes |
2016-01-01 | Plan benefit arrangement – Insurance | Yes |
2015: PSA BEHAVIORAL HEALTH AGENCY 2015 form 5500 responses |
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2015-01-01 | Type of plan entity | Single employer plan |
2015-01-01 | Submission has been amended | No |
2015-01-01 | This submission is the final filing | No |
2015-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2015-01-01 | Plan is a collectively bargained plan | No |
2015-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2015-01-01 | Plan benefit arrangement – Insurance | Yes |
2014: PSA BEHAVIORAL HEALTH AGENCY 2014 form 5500 responses |
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2014-12-01 | Type of plan entity | Single employer plan |
2014-12-01 | Submission has been amended | No |
2014-12-01 | This submission is the final filing | No |
2014-12-01 | This return/report is a short plan year return/report (less than 12 months) | Yes |
2014-12-01 | Plan is a collectively bargained plan | No |
2014-12-01 | Plan funding arrangement – Insurance | Yes |
2014-12-01 | Plan benefit arrangement – Insurance | Yes |
2014-01-01 | Type of plan entity | Single employer plan |
2014-01-01 | First time form 5500 has been submitted | Yes |
2014-01-01 | Submission has been amended | No |
2014-01-01 | This submission is the final filing | No |
2014-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2014-01-01 | Plan is a collectively bargained plan | No |
2014-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2014-01-01 | Plan benefit arrangement – Insurance | Yes |
2013: PSA BEHAVIORAL HEALTH AGENCY 2013 form 5500 responses |
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2013-10-01 | Type of plan entity | Single employer plan |
2013-10-01 | Submission has been amended | No |
2013-10-01 | This submission is the final filing | No |
2013-10-01 | This return/report is a short plan year return/report (less than 12 months) | Yes |
2013-10-01 | Plan is a collectively bargained plan | No |
2013-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2013-10-01 | Plan benefit arrangement – Insurance | Yes |
2012: PSA BEHAVIORAL HEALTH AGENCY 2012 form 5500 responses |
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2012-10-01 | Type of plan entity | Single employer plan |
2012-10-01 | First time form 5500 has been submitted | Yes |
2012-10-01 | Submission has been amended | No |
2012-10-01 | This submission is the final filing | No |
2012-10-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2012-10-01 | Plan is a collectively bargained plan | No |
2012-10-01 | Plan funding arrangement – Insurance | Yes |
2012-10-01 | Plan benefit arrangement – Insurance | Yes |
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
Policy contract number | 10259132 |
Policy instance | 3 |
Insurance contract or identification number | 10259132 | Number of Individuals Covered | 143 | Insurance policy start date | 2022-01-01 | Insurance policy end date | 2022-12-31 | Total amount of commissions paid to insurance broker | USD $10,705 | Total amount of fees paid to insurance company | USD $405 | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | Yes | Long Term Disability Insurance Welfare Benefit | Yes | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | ACCIDENT,ACCIDENTAL DEATH AND DISMEMBERMENT,CRITICAL ILLNESS | Welfare Benefit Premiums Paid to Carrier | USD $69,632 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $10,705 | Amount paid for insurance broker fees | 405 | Additional information about fees paid to insurance broker | BROKER BONUS | Insurance broker organization code? | 3 |
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UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
Policy contract number | 926755 |
Policy instance | 2 |
Insurance contract or identification number | 926755 | Number of Individuals Covered | 219 | Insurance policy start date | 2022-01-01 | Insurance policy end date | 2022-12-31 | Total amount of commissions paid to insurance broker | USD $5,628 | Total amount of fees paid to insurance company | USD $5,519 | Health Insurance Welfare Benefit | Yes | Dental Insurance Welfare Benefit | Yes | Vision Insurance Welfare Benefit | Yes | Other welfare benefits provided | TELEHEALTH | Welfare Benefit Premiums Paid to Carrier | USD $819,346 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $5,628 | Amount paid for insurance broker fees | 2312 | Additional information about fees paid to insurance broker | BONUS | Insurance broker organization code? | 3 |
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COMPSYCH (National Association of Insurance Commissioners NAIC id number: 00000 ) |
Policy contract number | CN3906K |
Policy instance | 1 |
Insurance contract or identification number | CN3906K | Number of Individuals Covered | 200 | Insurance policy start date | 2022-01-01 | Insurance policy end date | 2022-12-31 | Total amount of commissions paid to insurance broker | USD $0 | Total amount of fees paid to insurance company | USD $0 | Other welfare benefits provided | EMPLOYEE ASSISTANCE PROGRAM | Welfare Benefit Premiums Paid to Carrier | USD $4,325 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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BLUE CROSS BLUE SHIELD OF ARIZONA (National Association of Insurance Commissioners NAIC id number: 53589 ) |
Policy contract number | 30339 |
Policy instance | 1 |
Insurance contract or identification number | 30339 | Number of Individuals Covered | 154 | 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 | Health Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $806,134 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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COMPSYCH (National Association of Insurance Commissioners NAIC id number: 00000 ) |
Policy contract number | CN3906K |
Policy instance | 2 |
Insurance contract or identification number | CN3906K | Number of Individuals Covered | 1 | 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 | Other welfare benefits provided | EMPLOYEE ASSISTANCE PROGRAM | Welfare Benefit Premiums Paid to Carrier | USD $4,325 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 ) |
Policy contract number | 010-52879 |
Policy instance | 3 |
Insurance contract or identification number | 010-52879 | Number of Individuals Covered | 211 | Insurance policy start date | 2021-01-01 | Insurance policy end date | 2021-12-31 | Total amount of commissions paid to insurance broker | USD $4,535 | Total amount of fees paid to insurance company | USD $95 | Dental Insurance Welfare Benefit | Yes | Vision Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $45,353 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $4,535 | Amount paid for insurance broker fees | 95 | Additional information about fees paid to insurance broker | FEES | Insurance broker organization code? | 3 |
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EMPLOYERS DENTAL SERVICES (National Association of Insurance Commissioners NAIC id number: 53090 ) |
Policy contract number | 19581, 19582 |
Policy instance | 4 |
Insurance contract or identification number | 19581, 19582 | Number of Individuals Covered | 73 | Insurance policy start date | 2021-01-01 | Insurance policy end date | 2021-12-31 | Total amount of commissions paid to insurance broker | USD $707 | Total amount of fees paid to insurance company | USD $0 | Dental Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $8,953 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | Commission paid to Insurance Broker | USD $707 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
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THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
Policy contract number | 10259132 |
Policy instance | 5 |
Insurance contract or identification number | 10259132 | Number of Individuals Covered | 135 | Insurance policy start date | 2021-01-01 | Insurance policy end date | 2021-12-31 | Total amount of commissions paid to insurance broker | USD $7,859 | Total amount of fees paid to insurance company | USD $679 | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | Yes | Long Term Disability Insurance Welfare Benefit | Yes | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | ACCIDENT,ACCIDENTAL DEATH AND DISMEMBERMENT,CRITICAL ILLNESS | Welfare Benefit Premiums Paid to Carrier | USD $52,845 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $7,859 | Amount paid for insurance broker fees | 561 | Additional information about fees paid to insurance broker | BROKER BONUS | Insurance broker organization code? | 3 |
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BLUE CROSS BLUE SHIELD OF ARIZONA (National Association of Insurance Commissioners NAIC id number: 53589 ) |
Policy contract number | 30339 |
Policy instance | 1 |
Insurance contract or identification number | 30339 | Number of Individuals Covered | 91 | Insurance policy start date | 2020-01-01 | Insurance policy end date | 2020-12-31 | Total amount of commissions paid to insurance broker | USD $3,864 | Total amount of fees paid to insurance company | USD $0 | Health Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $742,790 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $3,864 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
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COMPSYCH (National Association of Insurance Commissioners NAIC id number: 00000 ) |
Policy contract number | CN3906K |
Policy instance | 2 |
Insurance contract or identification number | CN3906K | Number of Individuals Covered | 1 | 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 | Other welfare benefits provided | EMPLOYEE ASSISTANCE PROGRAM | Welfare Benefit Premiums Paid to Carrier | USD $4,325 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 ) |
Policy contract number | 010-52879 |
Policy instance | 3 |
Insurance contract or identification number | 010-52879 | Number of Individuals Covered | 330 | Insurance policy start date | 2020-01-01 | Insurance policy end date | 2020-12-31 | Total amount of commissions paid to insurance broker | USD $3,929 | Total amount of fees paid to insurance company | USD $627 | Dental Insurance Welfare Benefit | Yes | Vision Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $39,291 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $3,929 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 | Additional information about fees paid to insurance broker | FEES |
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EMPLOYERS DENTAL SERVICES (National Association of Insurance Commissioners NAIC id number: 53090 ) |
Policy contract number | 19581, 19582 |
Policy instance | 4 |
Insurance contract or identification number | 19581, 19582 | Number of Individuals Covered | 56 | Insurance policy start date | 2020-01-01 | Insurance policy end date | 2020-12-31 | Total amount of commissions paid to insurance broker | USD $826 | Total amount of fees paid to insurance company | USD $0 | Dental Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $8,372 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | Commission paid to Insurance Broker | USD $826 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
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THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
Policy contract number | 10259132 |
Policy instance | 5 |
Insurance contract or identification number | 10259132 | Number of Individuals Covered | 151 | Insurance policy start date | 2020-01-01 | Insurance policy end date | 2020-12-31 | Total amount of commissions paid to insurance broker | USD $5,280 | Total amount of fees paid to insurance company | USD $1,389 | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | Yes | Long Term Disability Insurance Welfare Benefit | Yes | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | ACCIDENT,ACCIDENTAL DEATH AND DISMEMBERMENT,CRITICAL ILLNESS | Welfare Benefit Premiums Paid to Carrier | USD $37,336 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $3,448 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 | Additional information about fees paid to insurance broker | BROKER BONUS |
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UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 ) |
Policy contract number | 5487529 |
Policy instance | 5 |
Insurance contract or identification number | 5487529 | Number of Individuals Covered | 105 | Insurance policy start date | 2019-01-01 | Insurance policy end date | 2019-12-31 | Total amount of commissions paid to insurance broker | USD $10,960 | Total amount of fees paid to insurance company | USD $117,600 | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | Yes | Vision Insurance Welfare Benefit | Yes | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | Yes | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | ACCIDENT, CRITICAL ILLNESS | Welfare Benefit Premiums Paid to Carrier | USD $83,803 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $5,653 | Insurance broker organization code? | 3 | Amount paid for insurance broker fees | 0 | Additional information about fees paid to insurance broker | FEES |
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UNION DENTAL CARE OF ARIZONA, INC. (National Association of Insurance Commissioners NAIC id number: 47708 ) |
Policy contract number | 5478529 |
Policy instance | 4 |
Insurance contract or identification number | 5478529 | Number of Individuals Covered | 54 | Insurance policy start date | 2019-01-01 | Insurance policy end date | 2019-12-31 | Total amount of commissions paid to insurance broker | USD $1,285 | Total amount of fees paid to insurance company | USD $219 | Dental Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $12,878 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $848 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 | Additional information about fees paid to insurance broker | FEES |
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COMPSYCH (National Association of Insurance Commissioners NAIC id number: 00000 ) |
Policy contract number | CN3906K |
Policy instance | 3 |
Insurance contract or identification number | CN3906K | Number of Individuals Covered | 1 | Insurance policy start date | 2019-01-01 | Insurance policy end date | 2019-12-31 | Total amount of commissions paid to insurance broker | USD $0 | Total amount of fees paid to insurance company | USD $0 | Other welfare benefits provided | EMPLOYEE ASSISTANCE PROGRAM | Welfare Benefit Premiums Paid to Carrier | USD $4,325 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
Policy contract number | 877038G |
Policy instance | 2 |
Insurance contract or identification number | 877038G | Number of Individuals Covered | 196 | Insurance policy start date | 2019-01-01 | Insurance policy end date | 2019-12-31 | Total amount of commissions paid to insurance broker | USD $2,161 | Total amount of fees paid to insurance company | USD $30 | Life Insurance Welfare Benefit | Yes | Long Term Disability Insurance Welfare Benefit | Yes | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | Welfare Benefit Premiums Paid to Carrier | USD $19,525 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $1,641 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 | Additional information about fees paid to insurance broker | BONUS |
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BLUE CROSS BLUE SHIELD OF ARIZONA (National Association of Insurance Commissioners NAIC id number: 53589 ) |
Policy contract number | 30339 |
Policy instance | 1 |
Insurance contract or identification number | 30339 | Number of Individuals Covered | 132 | Insurance policy start date | 2019-01-01 | Insurance policy end date | 2019-12-31 | Total amount of commissions paid to insurance broker | USD $45,854 | Total amount of fees paid to insurance company | USD $0 | Health Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $917,027 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $34,538 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
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UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 ) |
Policy contract number | 5487529 |
Policy instance | 5 |
Insurance contract or identification number | 5487529 | Number of Individuals Covered | 111 | Insurance policy start date | 2018-01-01 | Insurance policy end date | 2018-12-31 | Total amount of commissions paid to insurance broker | USD $7,359 | Total amount of fees paid to insurance company | USD $1,553 | 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 | Yes | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | ACCIDENT INSURANCE, CRITICAL ILLNESS INSURANCE | 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 $63,260 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $4,702 | Amount paid for insurance broker fees | 1553 | Additional information about fees paid to insurance broker | BONUS | Insurance broker organization code? | 3 |
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UNION DENTAL CARE OF ARIZONA, INC. (National Association of Insurance Commissioners NAIC id number: 47708 ) |
Policy contract number | 5487529 |
Policy instance | 4 |
Insurance contract or identification number | 5487529 | Number of Individuals Covered | 72 | Insurance policy start date | 2018-01-01 | Insurance policy end date | 2018-12-31 | Total amount of commissions paid to insurance broker | USD $1,527 | Total amount of fees paid to insurance company | USD $339 | 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 $15,238 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $956 | Amount paid for insurance broker fees | 339 | Additional information about fees paid to insurance broker | BONUS | Insurance broker organization code? | 3 |
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UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 ) |
Policy contract number | 4053559 |
Policy instance | 3 |
Insurance contract or identification number | 4053559 | Number of Individuals Covered | 33 | Insurance policy start date | 2018-01-01 | Insurance policy end date | 2018-12-31 | Total amount of commissions paid to insurance broker | USD $3,382 | 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 | Yes | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $15,053 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $1,804 | Insurance broker organization code? | 3 |
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HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
Policy contract number | 877038G |
Policy instance | 2 |
Insurance contract or identification number | 877038G | Number of Individuals Covered | 196 | Insurance policy start date | 2018-01-01 | Insurance policy end date | 2018-12-31 | Total amount of commissions paid to insurance broker | USD $3,630 | Total amount of fees paid to insurance company | USD $79 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | Yes | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | ADD | 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 $31,433 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $3,044 | Insurance broker organization code? | 3 | Amount paid for insurance broker fees | 79 | Additional information about fees paid to insurance broker | BONUS |
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BLUE CROSS BLUE SHIELD OF ARIZONA (National Association of Insurance Commissioners NAIC id number: 53589 ) |
Policy contract number | 30339 |
Policy instance | 1 |
Insurance contract or identification number | 30339 | Number of Individuals Covered | 134 | Insurance policy start date | 2018-01-01 | Insurance policy end date | 2018-12-31 | Total amount of commissions paid to insurance broker | USD $35,948 | 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 | Yes | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | Yes | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $791,084 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $25,304 | Insurance broker organization code? | 3 |
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BLUE CROSS BLUE SHIELD OF ARIZONA (National Association of Insurance Commissioners NAIC id number: 53589 ) |
Policy contract number | 30339 |
Policy instance | 1 |
Insurance contract or identification number | 30339 | Number of Individuals Covered | 114 | Insurance policy start date | 2017-01-01 | Insurance policy end date | 2017-12-31 | Total amount of commissions paid to insurance broker | USD $28,224 | 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 | Yes | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | Yes | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $564,827 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | Commission paid to Insurance Broker | USD $28,184 | Amount paid for insurance broker fees | 0 | Insurance broker name | MW BAGNALL COMPANY |
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HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
Policy contract number | 877038G |
Policy instance | 2 |
Insurance contract or identification number | 877038G | Number of Individuals Covered | 180 | Insurance policy start date | 2017-01-01 | Insurance policy end date | 2017-12-31 | Total amount of commissions paid to insurance broker | USD $1,441 | 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 | Yes | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | Yes | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | AD&D | 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 $19,843 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $1,210 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 | Insurance broker name | GALLAGHER BENEFIT SVCS INC |
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MHN SERVICES (National Association of Insurance Commissioners NAIC id number: 52411 ) |
Policy contract number | 002347 |
Policy instance | 3 |
Insurance contract or identification number | 002347 | Number of Individuals Covered | 125 | Insurance policy start date | 2017-01-01 | Insurance policy end date | 2017-12-31 | Total amount of commissions paid to insurance broker | USD $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 | Other welfare benefits provided | EAP | 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 $2,882 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
Policy contract number | KM05932512 |
Policy instance | 4 |
Insurance contract or identification number | KM05932512 | Number of Individuals Covered | 166 | Insurance policy start date | 2017-01-01 | Insurance policy end date | 2017-12-31 | Total amount of commissions paid to insurance broker | USD $3,434 | Total amount of fees paid to insurance company | USD $140 | 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 | Yes | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $50,430 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $3,434 | Amount paid for insurance broker fees | 140 | Additional information about fees paid to insurance broker | NON-MONETARY COMPENSATION | Insurance broker organization code? | 3 | Insurance broker name | BENEFIT COMMERCE GROUP LLC |
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EMPLOYERS DENTAL SERVICES (National Association of Insurance Commissioners NAIC id number: 53090 ) |
Policy contract number | 17436 |
Policy instance | 5 |
Insurance contract or identification number | 17436 | Number of Individuals Covered | 90 | Insurance policy start date | 2017-01-01 | Insurance policy end date | 2017-12-31 | Total amount of commissions paid to insurance broker | USD $721 | 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 $9,118 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | Commission paid to Insurance Broker | USD $721 | Amount paid for insurance broker fees | 0 | Insurance broker name | BENEFIT COMMERCE GROUP LLC |
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UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 ) |
Policy contract number | 4053559 |
Policy instance | 6 |
Insurance contract or identification number | 4053559 | Number of Individuals Covered | 39 | Insurance policy start date | 2017-01-01 | Insurance policy end date | 2017-12-31 | Total amount of commissions paid to insurance broker | USD $2,023 | 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 | Yes | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $16,985 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $2,023 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 | Insurance broker name | BENEFIT COMMERCE GROUP LLC |
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VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
Policy contract number | 30021671 |
Policy instance | 1 |
Insurance contract or identification number | 30021671 | Number of Individuals Covered | 75 | Insurance policy start date | 2015-01-01 | Insurance policy end date | 2015-12-31 | Total amount of commissions paid to insurance broker | USD $389 | Total amount of fees paid to insurance company | USD $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 plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | Yes | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $8,834 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $389 | Insurance broker organization code? | 3 | Insurance broker name | THE BAGNALL COMPANY |
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SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
Policy contract number | 239189 |
Policy instance | 2 |
Insurance contract or identification number | 239189 | Number of Individuals Covered | 149 | Insurance policy start date | 2015-01-01 | Insurance policy end date | 2015-12-31 | Total amount of commissions paid to insurance broker | USD $1,451 | Total amount of fees paid to insurance company | USD $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 plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $13,931 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $879 | Insurance broker organization code? | 3 | Insurance broker name | DAVID SPELLICY |
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BLUE CROSS BLUE SHIELD OF ARIZONA (National Association of Insurance Commissioners NAIC id number: 53589 ) |
Policy contract number | 30339 |
Policy instance | 3 |
Insurance contract or identification number | 30339 | Number of Individuals Covered | 94 | Insurance policy start date | 2015-01-01 | Insurance policy end date | 2015-12-31 | Total amount of commissions paid to insurance broker | USD $18,004 | Total amount of fees paid to insurance company | USD $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 plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | Yes | Dental Insurance Welfare Benefit | 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 $411,722 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $18,004 | Insurance broker organization code? | 3 | Insurance broker name | THE SPELLICY GROUP INC. |
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UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 ) |
Policy contract number | 4053559 |
Policy instance | 4 |
Insurance contract or identification number | 4053559 | Number of Individuals Covered | 24 | Insurance policy start date | 2015-01-01 | Insurance policy end date | 2015-12-31 | Total amount of commissions paid to insurance broker | USD $1,493 | Total amount of fees paid to insurance company | USD $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 plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | Yes | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | CANCER | 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 $7,578 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $1,493 | Insurance broker organization code? | 3 | Insurance broker name | THE BAGNALL COMPANY |
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EMPLOYERS DENTAL SERVICES (National Association of Insurance Commissioners NAIC id number: 53090 ) |
Policy contract number | 17436-17438 |
Policy instance | 5 |
Insurance contract or identification number | 17436-17438 | Number of Individuals Covered | 58 | Insurance policy start date | 2015-01-01 | Insurance policy end date | 2015-12-31 | Total amount of commissions paid to insurance broker | USD $665 | Total amount of fees paid to insurance company | USD $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 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 $8,430 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $469 | Insurance broker organization code? | 3 | Insurance broker name | THE SPELLICY GROUP |
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PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 ) |
Policy contract number | 1013465 |
Policy instance | 6 |
Insurance contract or identification number | 1013465 | Number of Individuals Covered | 62 | Insurance policy start date | 2015-01-01 | Insurance policy end date | 2015-12-31 | Total amount of commissions paid to insurance broker | USD $2,421 | Total amount of fees paid to insurance company | USD $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 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 $37,994 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $1,483 | Insurance broker organization code? | 3 | Insurance broker name | THE SPELLICY GROUP INC. |
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BLUE CROSS BLUE SHIELD OF ARIZONA (National Association of Insurance Commissioners NAIC id number: 53589 ) |
Policy contract number | 30339 |
Policy instance | 1 |
Insurance contract or identification number | 30339 | Number of Individuals Covered | 87 | Insurance policy start date | 2014-12-01 | Insurance policy end date | 2014-12-31 | Total amount of commissions paid to insurance broker | USD $1,506 | 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 plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | Yes | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | Yes | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 ) |
Policy contract number | H39950 |
Policy instance | 1 |
Insurance contract or identification number | H39950 | Number of Individuals Covered | 159 | Insurance policy start date | 2014-01-01 | Insurance policy end date | 2014-12-31 | Total amount of commissions paid to insurance broker | USD $1,516 | Total amount of fees paid to insurance company | USD $198 | 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 plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | 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 $11,018 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $1,516 | Amount paid for insurance broker fees | 198 | Additional information about fees paid to insurance broker | BONUS | Insurance broker organization code? | 3 | Insurance broker name | THE SPELLICY GROUP INC |
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PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 ) |
Policy contract number | H39950 |
Policy instance | 1 |
Insurance contract or identification number | H39950 | Number of Individuals Covered | 137 | Insurance policy start date | 2013-10-10 | Insurance policy end date | 2013-12-31 | Total amount of commissions paid to insurance broker | USD $391 | 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 plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | 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 $2,844 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $391 | Insurance broker organization code? | 3 | Insurance broker name | THE SPELLICY GROUP INC |
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MHN SERVICES (National Association of Insurance Commissioners NAIC id number: 52411 ) |
Policy contract number | 2347 |
Policy instance | 1 |
Insurance contract or identification number | 2347 | Number of Individuals Covered | 125 | Insurance policy start date | 2013-10-01 | Insurance policy end date | 2014-09-30 | 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? | 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 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 $1,900 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 ) |
Policy contract number | H39950 |
Policy instance | 1 |
Insurance contract or identification number | H39950 | Number of Individuals Covered | 123 | Insurance policy start date | 2012-10-01 | Insurance policy end date | 2013-09-30 | Total amount of commissions paid to insurance broker | USD $1,357 | 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 plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | 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 $9,604 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $1,357 | Insurance broker organization code? | 3 | Insurance broker name | THE SPELLICY GROUP INC |
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