GOODWILL INDUSTRIES OF SOUTHERN ARIZONA, INC. has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan GOODWILL INDUSTRIES OF SOUTHERN ARIZONA INC EMPLOYEE WELFARE BENEFIT PLAN
401k plan membership statisitcs for GOODWILL INDUSTRIES OF SOUTHERN ARIZONA INC EMPLOYEE WELFARE BENEFIT PLAN
| Measure | Date | Value |
|---|
| 2022: GOODWILL INDUSTRIES OF SOUTHERN ARIZONA INC EMPLOYEE WELFARE BENEFIT PLAN 2022 401k membership |
|---|
| Total participants, beginning-of-year | 2022-07-01 | 182 |
| Total number of active participants reported on line 7a of the Form 5500 | 2022-07-01 | 180 |
| Number of retired or separated participants receiving benefits | 2022-07-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2022-07-01 | 0 |
| Total of all active and inactive participants | 2022-07-01 | 180 |
| Number of employers contributing to the scheme | 2022-07-01 | 0 |
| 2021: GOODWILL INDUSTRIES OF SOUTHERN ARIZONA INC EMPLOYEE WELFARE BENEFIT PLAN 2021 401k membership |
|---|
| Total participants, beginning-of-year | 2021-07-01 | 123 |
| Total number of active participants reported on line 7a of the Form 5500 | 2021-07-01 | 182 |
| Number of retired or separated participants receiving benefits | 2021-07-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2021-07-01 | 0 |
| Total of all active and inactive participants | 2021-07-01 | 182 |
| Number of employers contributing to the scheme | 2021-07-01 | 0 |
| 2020: GOODWILL INDUSTRIES OF SOUTHERN ARIZONA INC EMPLOYEE WELFARE BENEFIT PLAN 2020 401k membership |
|---|
| Total participants, beginning-of-year | 2020-07-01 | 178 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-07-01 | 123 |
| Number of retired or separated participants receiving benefits | 2020-07-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2020-07-01 | 0 |
| Total of all active and inactive participants | 2020-07-01 | 123 |
| Number of employers contributing to the scheme | 2020-07-01 | 0 |
| 2019: GOODWILL INDUSTRIES OF SOUTHERN ARIZONA INC EMPLOYEE WELFARE BENEFIT PLAN 2019 401k membership |
|---|
| Total participants, beginning-of-year | 2019-07-01 | 205 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-07-01 | 178 |
| Number of retired or separated participants receiving benefits | 2019-07-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2019-07-01 | 0 |
| Total of all active and inactive participants | 2019-07-01 | 178 |
| Number of employers contributing to the scheme | 2019-07-01 | 0 |
| 2018: GOODWILL INDUSTRIES OF SOUTHERN ARIZONA INC EMPLOYEE WELFARE BENEFIT PLAN 2018 401k membership |
|---|
| Total participants, beginning-of-year | 2018-07-01 | 226 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-07-01 | 205 |
| Number of retired or separated participants receiving benefits | 2018-07-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2018-07-01 | 0 |
| Total of all active and inactive participants | 2018-07-01 | 205 |
| Number of employers contributing to the scheme | 2018-07-01 | 0 |
| 2017: GOODWILL INDUSTRIES OF SOUTHERN ARIZONA INC EMPLOYEE WELFARE BENEFIT PLAN 2017 401k membership |
|---|
| Total participants, beginning-of-year | 2017-07-01 | 197 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-07-01 | 162 |
| Number of retired or separated participants receiving benefits | 2017-07-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2017-07-01 | 0 |
| Total of all active and inactive participants | 2017-07-01 | 162 |
| Number of employers contributing to the scheme | 2017-07-01 | 0 |
| 2016: GOODWILL INDUSTRIES OF SOUTHERN ARIZONA INC EMPLOYEE WELFARE BENEFIT PLAN 2016 401k membership |
|---|
| Total participants, beginning-of-year | 2016-07-01 | 214 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-07-01 | 197 |
| Number of retired or separated participants receiving benefits | 2016-07-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2016-07-01 | 0 |
| Total of all active and inactive participants | 2016-07-01 | 197 |
| 2015: GOODWILL INDUSTRIES OF SOUTHERN ARIZONA INC EMPLOYEE WELFARE BENEFIT PLAN 2015 401k membership |
|---|
| Total participants, beginning-of-year | 2015-07-01 | 226 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-07-01 | 214 |
| Total of all active and inactive participants | 2015-07-01 | 214 |
| 2014: GOODWILL INDUSTRIES OF SOUTHERN ARIZONA INC EMPLOYEE WELFARE BENEFIT PLAN 2014 401k membership |
|---|
| Total participants, beginning-of-year | 2014-07-01 | 410 |
| Total number of active participants reported on line 7a of the Form 5500 | 2014-07-01 | 376 |
| Number of retired or separated participants receiving benefits | 2014-07-01 | 1 |
| Total of all active and inactive participants | 2014-07-01 | 377 |
| 2013: GOODWILL INDUSTRIES OF SOUTHERN ARIZONA INC EMPLOYEE WELFARE BENEFIT PLAN 2013 401k membership |
|---|
| Total participants, beginning-of-year | 2013-07-01 | 372 |
| Total number of active participants reported on line 7a of the Form 5500 | 2013-07-01 | 400 |
| Total of all active and inactive participants | 2013-07-01 | 400 |
| 2012: GOODWILL INDUSTRIES OF SOUTHERN ARIZONA INC EMPLOYEE WELFARE BENEFIT PLAN 2012 401k membership |
|---|
| Total participants, beginning-of-year | 2012-07-01 | 155 |
| Total number of active participants reported on line 7a of the Form 5500 | 2012-07-01 | 376 |
| Total of all active and inactive participants | 2012-07-01 | 376 |
| 2011: GOODWILL INDUSTRIES OF SOUTHERN ARIZONA INC EMPLOYEE WELFARE BENEFIT PLAN 2011 401k membership |
|---|
| Total participants, beginning-of-year | 2011-08-01 | 139 |
| Total number of active participants reported on line 7a of the Form 5500 | 2011-08-01 | 155 |
| Total of all active and inactive participants | 2011-08-01 | 155 |
| 2022: GOODWILL INDUSTRIES OF SOUTHERN ARIZONA INC EMPLOYEE WELFARE BENEFIT PLAN 2022 form 5500 responses |
|---|
| 2022-07-01 | Type of plan entity | Single employer plan |
| 2022-07-01 | Plan funding arrangement – Insurance | Yes |
| 2022-07-01 | Plan benefit arrangement – Insurance | Yes |
| 2021: GOODWILL INDUSTRIES OF SOUTHERN ARIZONA INC EMPLOYEE WELFARE BENEFIT PLAN 2021 form 5500 responses |
|---|
| 2021-07-01 | Type of plan entity | Single employer plan |
| 2021-07-01 | Plan funding arrangement – Insurance | Yes |
| 2021-07-01 | Plan benefit arrangement – Insurance | Yes |
| 2020: GOODWILL INDUSTRIES OF SOUTHERN ARIZONA INC EMPLOYEE WELFARE BENEFIT PLAN 2020 form 5500 responses |
|---|
| 2020-07-01 | Type of plan entity | Single employer plan |
| 2020-07-01 | Plan funding arrangement – Insurance | Yes |
| 2020-07-01 | Plan benefit arrangement – Insurance | Yes |
| 2019: GOODWILL INDUSTRIES OF SOUTHERN ARIZONA INC EMPLOYEE WELFARE BENEFIT PLAN 2019 form 5500 responses |
|---|
| 2019-07-01 | Type of plan entity | Single employer plan |
| 2019-07-01 | Submission has been amended | Yes |
| 2019-07-01 | Plan funding arrangement – Insurance | Yes |
| 2019-07-01 | Plan benefit arrangement – Insurance | Yes |
| 2018: GOODWILL INDUSTRIES OF SOUTHERN ARIZONA INC EMPLOYEE WELFARE BENEFIT PLAN 2018 form 5500 responses |
|---|
| 2018-07-01 | Type of plan entity | Single employer plan |
| 2018-07-01 | Plan funding arrangement – Insurance | Yes |
| 2018-07-01 | Plan benefit arrangement – Insurance | Yes |
| 2017: GOODWILL INDUSTRIES OF SOUTHERN ARIZONA INC EMPLOYEE WELFARE BENEFIT PLAN 2017 form 5500 responses |
|---|
| 2017-07-01 | Type of plan entity | Single employer plan |
| 2017-07-01 | Plan funding arrangement – Insurance | Yes |
| 2017-07-01 | Plan benefit arrangement – Insurance | Yes |
| 2016: GOODWILL INDUSTRIES OF SOUTHERN ARIZONA INC EMPLOYEE WELFARE BENEFIT PLAN 2016 form 5500 responses |
|---|
| 2016-07-01 | Type of plan entity | Single employer plan |
| 2016-07-01 | Submission has been amended | No |
| 2016-07-01 | This submission is the final filing | No |
| 2016-07-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2016-07-01 | Plan is a collectively bargained plan | No |
| 2016-07-01 | Plan funding arrangement – Insurance | Yes |
| 2016-07-01 | Plan benefit arrangement – Insurance | Yes |
| 2015: GOODWILL INDUSTRIES OF SOUTHERN ARIZONA INC EMPLOYEE WELFARE BENEFIT PLAN 2015 form 5500 responses |
|---|
| 2015-07-01 | Type of plan entity | Single employer plan |
| 2015-07-01 | Submission has been amended | No |
| 2015-07-01 | This submission is the final filing | No |
| 2015-07-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2015-07-01 | Plan is a collectively bargained plan | No |
| 2015-07-01 | Plan funding arrangement – Insurance | Yes |
| 2015-07-01 | Plan benefit arrangement – Insurance | Yes |
| 2014: GOODWILL INDUSTRIES OF SOUTHERN ARIZONA INC EMPLOYEE WELFARE BENEFIT PLAN 2014 form 5500 responses |
|---|
| 2014-07-01 | Type of plan entity | Single employer plan |
| 2014-07-01 | Submission has been amended | No |
| 2014-07-01 | This submission is the final filing | No |
| 2014-07-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2014-07-01 | Plan is a collectively bargained plan | No |
| 2014-07-01 | Plan funding arrangement – Insurance | Yes |
| 2014-07-01 | Plan benefit arrangement – Insurance | Yes |
| 2013: GOODWILL INDUSTRIES OF SOUTHERN ARIZONA INC EMPLOYEE WELFARE BENEFIT PLAN 2013 form 5500 responses |
|---|
| 2013-07-01 | Type of plan entity | Single employer plan |
| 2013-07-01 | Submission has been amended | No |
| 2013-07-01 | This submission is the final filing | No |
| 2013-07-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2013-07-01 | Plan is a collectively bargained plan | No |
| 2013-07-01 | Plan funding arrangement – Insurance | Yes |
| 2013-07-01 | Plan benefit arrangement – Insurance | Yes |
| 2012: GOODWILL INDUSTRIES OF SOUTHERN ARIZONA INC EMPLOYEE WELFARE BENEFIT PLAN 2012 form 5500 responses |
|---|
| 2012-07-01 | Type of plan entity | Single employer plan |
| 2012-07-01 | Submission has been amended | No |
| 2012-07-01 | This submission is the final filing | No |
| 2012-07-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2012-07-01 | Plan is a collectively bargained plan | No |
| 2012-07-01 | Plan funding arrangement – Insurance | Yes |
| 2012-07-01 | Plan benefit arrangement – Insurance | Yes |
| 2011: GOODWILL INDUSTRIES OF SOUTHERN ARIZONA INC EMPLOYEE WELFARE BENEFIT PLAN 2011 form 5500 responses |
|---|
| 2011-08-01 | Type of plan entity | Single employer plan |
| 2011-08-01 | Submission has been amended | No |
| 2011-08-01 | This submission is the final filing | No |
| 2011-08-01 | This return/report is a short plan year return/report (less than 12 months) | Yes |
| 2011-08-01 | Plan is a collectively bargained plan | No |
| 2011-08-01 | Plan funding arrangement – Insurance | Yes |
| 2011-08-01 | Plan benefit arrangement – Insurance | Yes |
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 755138 |
| Policy instance | 4 |
| Insurance contract or identification number | 755138 | | Number of Individuals Covered | 336 | | Insurance policy start date | 2022-07-01 | | Insurance policy end date | 2023-06-30 | | Total amount of commissions paid to insurance broker | USD $9,943 | | Total amount of fees paid to insurance company | USD $86,649 | | Health Insurance Welfare Benefit | Yes | | 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, CRITICAL ILLNESS, HOSPITAL | | Welfare Benefit Premiums Paid to Carrier | USD $1,166,563 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,432 | | Amount paid for insurance broker fees | 84049 | | Additional information about fees paid to insurance broker | SERVICE FEE AGREEMENT | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUPR0C4G2 |
| Policy instance | 3 |
| Insurance contract or identification number | GUPR0C4G2 | | Number of Individuals Covered | 112 | | Insurance policy start date | 2022-07-01 | | Insurance policy end date | 2023-06-30 | | Total amount of commissions paid to insurance broker | USD $7,954 | | Total amount of fees paid to insurance company | USD $3,154 | | 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 | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $69,580 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,954 | | Amount paid for insurance broker fees | 3154 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| UNITED BEHAVIORAL HEALTH DBA OPTUM (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 1257870 |
| Policy instance | 2 |
| Insurance contract or identification number | 1257870 | | Number of Individuals Covered | 614 | | Insurance policy start date | 2022-07-01 | | Insurance policy end date | 2023-06-30 | | 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 $10,374 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MEMD (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 1363 |
| Policy instance | 1 |
| Insurance contract or identification number | 1363 | | Number of Individuals Covered | 180 | | Insurance policy start date | 2022-07-01 | | Insurance policy end date | 2023-06-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | TELEHEALTH | | Welfare Benefit Premiums Paid to Carrier | USD $57,493 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
| Policy contract number | 5357330 |
| Policy instance | 1 |
| Insurance contract or identification number | 5357330 | | Number of Individuals Covered | 117 | | Insurance policy start date | 2021-07-01 | | Insurance policy end date | 2022-06-30 | | Total amount of commissions paid to insurance broker | USD $6,207 | | Total amount of fees paid to insurance company | USD $1,476 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability 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 $72,836 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,768 | | Amount paid for insurance broker fees | 34 | | Additional information about fees paid to insurance broker | NON-MONETARY COMPENSATION | | Insurance broker organization code? | 3 |
|
| MEMD (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 1363 |
| Policy instance | 2 |
| Insurance contract or identification number | 1363 | | Number of Individuals Covered | 182 | | Insurance policy start date | 2021-07-01 | | Insurance policy end date | 2022-06-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | TELEHEALTH | | Welfare Benefit Premiums Paid to Carrier | USD $52,639 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 755138 |
| Policy instance | 3 |
| Insurance contract or identification number | 755138 | | Number of Individuals Covered | 464 | | Insurance policy start date | 2021-07-01 | | Insurance policy end date | 2022-06-30 | | Total amount of commissions paid to insurance broker | USD $4,134 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,130,067 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,134 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 ) |
| Policy contract number | V8405 |
| Policy instance | 4 |
| Insurance contract or identification number | V8405 | | Number of Individuals Covered | 899 | | Insurance policy start date | 2021-07-01 | | Insurance policy end date | 2022-06-30 | | Total amount of commissions paid to insurance broker | USD $5,860 | | Total amount of fees paid to insurance company | USD $0 | | 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 | ACCIDENT, CRITICAL ILLNESS,HOSPITAL | | Welfare Benefit Premiums Paid to Carrier | USD $19,170 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,585 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
| Policy contract number | 5357330 |
| Policy instance | 1 |
| Insurance contract or identification number | 5357330 | | Number of Individuals Covered | 123 | | Insurance policy start date | 2020-07-01 | | Insurance policy end date | 2021-06-30 | | Total amount of commissions paid to insurance broker | USD $7,522 | | Total amount of fees paid to insurance company | USD $3,240 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability 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 $63,618 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,198 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Additional information about fees paid to insurance broker | ADMINISTRATION FEES |
|
| MEMD (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 1363 |
| Policy instance | 2 |
| Insurance contract or identification number | 1363 | | Number of Individuals Covered | 501 | | Insurance policy start date | 2020-07-01 | | Insurance policy end date | 2021-06-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | TELEMEDICINE | | Welfare Benefit Premiums Paid to Carrier | USD $27,343 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 755138 |
| Policy instance | 3 |
| Insurance contract or identification number | 755138 | | Number of Individuals Covered | 160 | | Insurance policy start date | 2020-07-01 | | Insurance policy end date | 2021-06-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $52,157 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $976,478 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $0 | | Amount paid for insurance broker fees | 52157 | | Additional information about fees paid to insurance broker | SERVICE FEE AGREEMENT BONUS | | Insurance broker organization code? | 3 |
|
| AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 ) |
| Policy contract number | V8405 |
| Policy instance | 4 |
| Insurance contract or identification number | V8405 | | Number of Individuals Covered | 32 | | Insurance policy start date | 2020-07-01 | | Insurance policy end date | 2021-06-30 | | Total amount of commissions paid to insurance broker | USD $3,769 | | Total amount of fees paid to insurance company | USD $0 | | 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 | ACCIDENT, CRITICAL ILLNESS,HOSPITAL | | Welfare Benefit Premiums Paid to Carrier | USD $15,641 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,554 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| MEMD (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 1363 |
| Policy instance | 2 |
| Insurance contract or identification number | 1363 | | Number of Individuals Covered | 360 | | Insurance policy start date | 2019-07-01 | | Insurance policy end date | 2020-06-30 | | Total amount of commissions paid to insurance broker | USD $372 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | TELEMEDICINE | | Welfare Benefit Premiums Paid to Carrier | USD $16,438 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $372 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 755138 |
| Policy instance | 3 |
| Insurance contract or identification number | 755138 | | Number of Individuals Covered | 198 | | Insurance policy start date | 2019-07-01 | | Insurance policy end date | 2020-06-30 | | Total amount of commissions paid to insurance broker | USD $37,912 | | Total amount of fees paid to insurance company | USD $67,727 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,201,890 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $37,912 | | Amount paid for insurance broker fees | 67727 | | Additional information about fees paid to insurance broker | SERVICE FEE AGREEMENT | | Insurance broker organization code? | 3 |
|
| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
| Policy contract number | 3338931 |
| Policy instance | 4 |
| Insurance contract or identification number | 3338931 | | Number of Individuals Covered | 178 | | Insurance policy start date | 2019-07-01 | | Insurance policy end date | 2020-06-30 | | Total amount of commissions paid to insurance broker | USD $7,312 | | Total amount of fees paid to insurance company | USD $4,863 | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $98,591 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,314 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Additional information about fees paid to insurance broker | GENERAL AGENT PAYMENTS |
|
| AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 ) |
| Policy contract number | V8405 |
| Policy instance | 5 |
| Insurance contract or identification number | V8405 | | Number of Individuals Covered | 39 | | Insurance policy start date | 2019-07-01 | | Insurance policy end date | 2020-06-30 | | Total amount of commissions paid to insurance broker | USD $3,840 | | Total amount of fees paid to insurance company | USD $0 | | 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 | ACCIDENT, CRITICAL ILLNESS,HOSPITAL | | Welfare Benefit Premiums Paid to Carrier | USD $20,547 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,568 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
| Policy contract number | 5357330 |
| Policy instance | 1 |
| Insurance contract or identification number | 5357330 | | Number of Individuals Covered | 124 | | Insurance policy start date | 2019-07-01 | | Insurance policy end date | 2020-06-30 | | Total amount of commissions paid to insurance broker | USD $7,214 | | Total amount of fees paid to insurance company | USD $5,045 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability 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 $72,506 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,214 | | Amount paid for insurance broker fees | 1420 | | Additional information about fees paid to insurance broker | SUPPLEMENTAL COMPENSATION NON-MONETARY COMPENSATION | | Insurance broker organization code? | 3 |
|
| MEMD (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 1363 |
| Policy instance | 2 |
| Insurance contract or identification number | 1363 | | Number of Individuals Covered | 205 | | Insurance policy start date | 2018-07-01 | | Insurance policy end date | 2019-06-30 | | Total amount of commissions paid to insurance broker | USD $288 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | TELEMEDICINE | | Welfare Benefit Premiums Paid to Carrier | USD $2,194 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $288 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 ) |
| Policy contract number | V8405 |
| Policy instance | 3 |
| Insurance contract or identification number | V8405 | | Number of Individuals Covered | 32 | | Insurance policy start date | 2018-07-01 | | Insurance policy end date | 2019-06-30 | | Total amount of commissions paid to insurance broker | USD $3,698 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | ACCIDENT, CRITICAL ILLNESS | | Welfare Benefit Premiums Paid to Carrier | USD $14,663 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,968 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 755138 |
| Policy instance | 4 |
| Insurance contract or identification number | 755138 | | Number of Individuals Covered | 246 | | Insurance policy start date | 2018-07-01 | | Insurance policy end date | 2019-06-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $47,654 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $991,668 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $0 | | Amount paid for insurance broker fees | 47654 | | Additional information about fees paid to insurance broker | SERVICE FEE AGREEMENT | | Insurance broker organization code? | 3 |
|
| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
| Policy contract number | 3338931 |
| Policy instance | 5 |
| Insurance contract or identification number | 3338931 | | Number of Individuals Covered | 211 | | Insurance policy start date | 2018-07-01 | | Insurance policy end date | 2019-06-30 | | Total amount of commissions paid to insurance broker | USD $7,155 | | Total amount of fees paid to insurance company | USD $5,775 | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $105,277 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,155 | | Amount paid for insurance broker fees | 568 | | Additional information about fees paid to insurance broker | GENERAL AGENT PAYMENTS | | Insurance broker organization code? | 3 |
|
| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
| Policy contract number | 5357330 |
| Policy instance | 1 |
| Insurance contract or identification number | 5357330 | | Number of Individuals Covered | 146 | | Insurance policy start date | 2018-07-01 | | Insurance policy end date | 2019-06-30 | | Total amount of commissions paid to insurance broker | USD $6,801 | | Total amount of fees paid to insurance company | USD $4,604 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability 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 $67,910 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,801 | | Amount paid for insurance broker fees | 1209 | | Additional information about fees paid to insurance broker | SUPPLEMENTAL COMPENSATION NON MONETARY COMPENSATION | | Insurance broker organization code? | 3 |
|
| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
| Policy contract number | 05357330 |
| Policy instance | 1 |
| Insurance contract or identification number | 05357330 | | Number of Individuals Covered | 162 | | Insurance policy start date | 2017-07-01 | | Insurance policy end date | 2018-06-30 | | Total amount of commissions paid to insurance broker | USD $8,575 | | Total amount of fees paid to insurance company | USD $7,417 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability 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 $84,445 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,575 | | Amount paid for insurance broker fees | 3195 | | Additional information about fees paid to insurance broker | SUPPLEMENTAL COMPENSATION NON-MONETARY COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | LIAZON BENEFITS, INC. |
|
| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
| Policy contract number | 3338931 |
| Policy instance | 6 |
| Insurance contract or identification number | 3338931 | | Number of Individuals Covered | 202 | | Insurance policy start date | 2017-07-01 | | Insurance policy end date | 2018-06-30 | | Total amount of commissions paid to insurance broker | USD $7,447 | | Total amount of fees paid to insurance company | USD $4,945 | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $99,855 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,447 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Additional information about fees paid to insurance broker | SERVICE/GENERAL AGENT PAYMENTS | | Insurance broker name | LIAZON BENEFITS, INC. |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 755138 |
| Policy instance | 5 |
| Insurance contract or identification number | 755138 | | Number of Individuals Covered | 243 | | Insurance policy start date | 2017-07-01 | | Insurance policy end date | 2018-06-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $49,892 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $921,314 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $0 | | Amount paid for insurance broker fees | 49892 | | Additional information about fees paid to insurance broker | SERVICE FEE AGREEMENT | | Insurance broker organization code? | 3 | | Insurance broker name | LOVITT & TOUCHE INC |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 30040452 |
| Policy instance | 4 |
| Insurance contract or identification number | 30040452 | | Number of Individuals Covered | 981 | | Insurance policy start date | 2017-07-01 | | Insurance policy end date | 2018-06-30 | | Total amount of commissions paid to insurance broker | USD $7,464 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $74,637 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,464 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | BENEFIT COMMERCE GROUP LLC |
|
| AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 ) |
| Policy contract number | V8405 |
| Policy instance | 3 |
| Insurance contract or identification number | V8405 | | Number of Individuals Covered | 41 | | Insurance policy start date | 2017-07-01 | | Insurance policy end date | 2018-06-30 | | Total amount of commissions paid to insurance broker | USD $4,941 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | ACCIDENT, CRITICAL ILLNESS | | Welfare Benefit Premiums Paid to Carrier | USD $20,246 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,525 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | LIAZON BENEFITS, INC. |
|
| MEMD (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 839/840/841 |
| Policy instance | 2 |
| Insurance contract or identification number | 839/840/841 | | Number of Individuals Covered | 16 | | Insurance policy start date | 2017-07-01 | | Insurance policy end date | 2018-06-30 | | Total amount of commissions paid to insurance broker | USD $401 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | TELEMEDICINE | | Welfare Benefit Premiums Paid to Carrier | USD $2,776 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $401 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | LOVITT AND TOUCHE, INC. |
|
| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
| Policy contract number | 3338931 |
| Policy instance | 2 |
| Insurance contract or identification number | 3338931 | | Number of Individuals Covered | 205 | | Insurance policy start date | 2015-07-01 | | Insurance policy end date | 2016-06-30 | | Total amount of commissions paid to insurance broker | USD $7,816 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $107,245 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,816 | | Insurance broker organization code? | 3 | | Insurance broker name | LOVITT TOUCHE INC |
|
| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
| Policy contract number | TS05357330 |
| Policy instance | 3 |
| Insurance contract or identification number | TS05357330 | | Number of Individuals Covered | 276 | | Insurance policy start date | 2015-07-01 | | Insurance policy end date | 2016-06-30 | | Total amount of commissions paid to insurance broker | USD $7,944 | | Total amount of fees paid to insurance company | USD $6,418 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ADD | | Welfare Benefit Premiums Paid to Carrier | USD $86,085 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,944 | | Amount paid for insurance broker fees | 2179 | | Additional information about fees paid to insurance broker | SUPPLEMENTAL COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | LIAZON BENEFITS INC |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 755138 |
| Policy instance | 4 |
| Insurance contract or identification number | 755138 | | Number of Individuals Covered | 258 | | Insurance policy start date | 2015-07-01 | | Insurance policy end date | 2016-06-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $51,166 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $900,133 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $0 | | Amount paid for insurance broker fees | 51166 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker organization code? | 3 | | Insurance broker name | LOVITT TOUCHE INC |
|
| AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 ) |
| Policy contract number | V8405 |
| Policy instance | 1 |
| Insurance contract or identification number | V8405 | | Number of Individuals Covered | 70 | | Insurance policy start date | 2015-07-01 | | Insurance policy end date | 2016-06-30 | | Total amount of commissions paid to insurance broker | USD $7,989 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $22,376 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,681 | | Insurance broker organization code? | 3 | | Insurance broker name | LOVITT TOUCHE INC |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 236764 |
| Policy instance | 1 |
| Insurance contract or identification number | 236764 | | Number of Individuals Covered | 385 | | Insurance policy start date | 2014-07-01 | | Insurance policy end date | 2015-06-30 | | Total amount of commissions paid to insurance broker | USD $4,219 | | Total amount of fees paid to insurance company | USD $749 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ADD | | Welfare Benefit Premiums Paid to Carrier | USD $38,675 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,219 | | Amount paid for insurance broker fees | 749 | | Additional information about fees paid to insurance broker | BONUS | | Insurance broker organization code? | 3 | | Insurance broker name | LOVITT TOUCHE INC |
|
| COMPANION LIFE (National Association of Insurance Commissioners NAIC id number: 77828 ) |
| Policy contract number | AZH46361 |
| Policy instance | 2 |
| Insurance contract or identification number | AZH46361 | | Number of Individuals Covered | 139 | | Insurance policy start date | 2014-07-01 | | Insurance policy end date | 2015-06-30 | | Total amount of commissions paid to insurance broker | USD $6,503 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $60,359 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,503 | | Insurance broker organization code? | 3 | | Insurance broker name | CSA GENERAL INSURANCE AGENCY |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 755138 |
| Policy instance | 3 |
| Insurance contract or identification number | 755138 | | Number of Individuals Covered | 221 | | Insurance policy start date | 2014-07-01 | | Insurance policy end date | 2015-06-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $51,710 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $909,092 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 51710 | | Additional information about fees paid to insurance broker | FEES AND BONUS | | Insurance broker organization code? | 3 | | Insurance broker name | LOVITT TOUCHE INC |
|
| TOTAL DENTAL ADMINISTRATORS (National Association of Insurance Commissioners NAIC id number: 52120 ) |
| Policy contract number | 649250 |
| Policy instance | 2 |
| Insurance contract or identification number | 649250 | | Number of Individuals Covered | 100 | | Insurance policy start date | 2013-07-01 | | Insurance policy end date | 2014-06-30 | | Total amount of commissions paid to insurance broker | USD $2,222 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $14,710 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,222 | | Insurance broker organization code? | 3 | | Insurance broker name | CSA GENERAL INSURANCE AGENCY |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 755138 |
| Policy instance | 5 |
| Insurance contract or identification number | 755138 | | Number of Individuals Covered | 260 | | Insurance policy start date | 2013-07-01 | | Insurance policy end date | 2014-06-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $45,529 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $803,998 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 45529 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker organization code? | 3 | | Insurance broker name | LOVITT TOUCHE INC |
|
| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
| Policy contract number | KM05984919 |
| Policy instance | 4 |
| Insurance contract or identification number | KM05984919 | | Number of Individuals Covered | 423 | | Insurance policy start date | 2013-07-01 | | Insurance policy end date | 2014-06-30 | | Total amount of commissions paid to insurance broker | USD $5,163 | | Total amount of fees paid to insurance company | USD $147 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ADD | | Welfare Benefit Premiums Paid to Carrier | USD $41,347 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,163 | | Amount paid for insurance broker fees | 147 | | Additional information about fees paid to insurance broker | SUPPLEMENTAL COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | LOVITT TOUCHE INC |
|
| AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 ) |
| Policy contract number | ARF77 |
| Policy instance | 3 |
| Insurance contract or identification number | ARF77 | | Number of Individuals Covered | 91 | | Insurance policy start date | 2013-07-01 | | Insurance policy end date | 2014-06-30 | | Total amount of commissions paid to insurance broker | USD $9,645 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $40,160 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,946 | | Insurance broker organization code? | 3 | | Insurance broker name | NANCY L SIGL |
|
| COMPANION LIFE (National Association of Insurance Commissioners NAIC id number: 77828 ) |
| Policy contract number | AZH46361 |
| Policy instance | 1 |
| Insurance contract or identification number | AZH46361 | | Number of Individuals Covered | 136 | | Insurance policy start date | 2013-07-01 | | Insurance policy end date | 2014-06-30 | | Total amount of commissions paid to insurance broker | USD $6,432 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $60,485 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,432 | | Insurance broker organization code? | 3 | | Insurance broker name | CSA GENERAL INSURANCE AGENCY |
|
| TOTAL DENTAL ADMINISTRATORS (National Association of Insurance Commissioners NAIC id number: 52120 ) |
| Policy contract number | 649250 |
| Policy instance | 2 |
| Insurance contract or identification number | 649250 | | Number of Individuals Covered | 116 | | Insurance policy start date | 2012-07-01 | | Insurance policy end date | 2013-06-30 | | Total amount of commissions paid to insurance broker | USD $2,029 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $13,685 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,029 | | Insurance broker organization code? | 3 | | Insurance broker name | CSA GENERAL INSURANCE AGENCY |
|
| AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 ) |
| Policy contract number | ARF77 |
| Policy instance | 3 |
| Insurance contract or identification number | ARF77 | | Number of Individuals Covered | 108 | | Insurance policy start date | 2012-07-01 | | Insurance policy end date | 2013-06-30 | | Total amount of commissions paid to insurance broker | USD $11,643 | | Total amount of fees paid to insurance company | USD $48 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $39,899 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,634 | | Amount paid for insurance broker fees | 22 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker organization code? | 3 | | Insurance broker name | CBIZ BENEFITS AND INS SVCS INC |
|
| BLUE CROSS BLUE SHIELD OF ARIZONA (National Association of Insurance Commissioners NAIC id number: 53589 ) |
| Policy contract number | 27292 |
| Policy instance | 4 |
| Insurance contract or identification number | 27292 | | Number of Individuals Covered | 186 | | Insurance policy start date | 2012-07-01 | | Insurance policy end date | 2013-06-30 | | Total amount of commissions paid to insurance broker | USD $35,265 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Other welfare benefits provided | BIODYNE | | Welfare Benefit Premiums Paid to Carrier | USD $705,303 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $35,265 | | Insurance broker organization code? | 3 | | Insurance broker name | LOVITT TOUCHE INC |
|
| COMPANION LIFE (National Association of Insurance Commissioners NAIC id number: 77828 ) |
| Policy contract number | AZH46361 |
| Policy instance | 1 |
| Insurance contract or identification number | AZH46361 | | Number of Individuals Covered | 144 | | Insurance policy start date | 2012-07-01 | | Insurance policy end date | 2013-06-30 | | Total amount of commissions paid to insurance broker | USD $5,637 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $55,463 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,637 | | Insurance broker organization code? | 3 | | Insurance broker name | CSA GENERAL INSURANCE AGENCY |
|
| BLUE CROSS BLUE SHIELD OF ARIZONA (National Association of Insurance Commissioners NAIC id number: 53589 ) |
| Policy contract number | 27292 |
| Policy instance | 1 |
| Insurance contract or identification number | 27292 | | Number of Individuals Covered | 144 | | Insurance policy start date | 2011-08-01 | | Insurance policy end date | 2012-06-30 | | Total amount of commissions paid to insurance broker | USD $25,212 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $504,250 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| BLUE CROSS BLUE SHIELD OF ARIZONA (National Association of Insurance Commissioners NAIC id number: 53589 ) |
| Policy contract number | 27292 |
| Policy instance | 1 |
| Insurance contract or identification number | 27292 | | Number of Individuals Covered | 117 | | Insurance policy start date | 2010-08-01 | | Insurance policy end date | 2011-07-31 | | Total amount of commissions paid to insurance broker | USD $19,516 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $390,327 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
