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STUDENT THERAPY, INC. HEALTH & WELFARE BENEFITS PLAN 401k Plan overview

Plan NameSTUDENT THERAPY, INC. HEALTH & WELFARE BENEFITS PLAN
Plan identification number 501

STUDENT THERAPY, INC. HEALTH & WELFARE BENEFITS PLAN Benefits

401k Plan TypeWelfare Benefit
Plan Features/Benefits
  • Health (other than dental or vision)
  • Life insurance
  • Dental
  • Vision
  • Other welfare benefit cover

401k Sponsoring company profile

STUDENT THERAPY INC has sponsored the creation of one or more 401k plans.

Company Name:STUDENT THERAPY INC
Employer identification number (EIN):861019671
NAIC Classification:561300

Form 5500 Filing Information

Submission information for form 5500 for 401k plan STUDENT THERAPY, INC. HEALTH & WELFARE BENEFITS PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5012021-10-01
5012020-10-01
5012019-10-01
5012018-10-01
5012017-10-01
5012016-10-01BRIAN PAULSEN BRIAN PAULSEN2018-04-20
5012015-10-01BRIAN PAULSEN
5012014-10-01BRIAN PAULSEN
5012013-10-01BRIAN PAULSEN
5012012-10-01BRIAN PAULSEN
5012011-10-01BRIAN PAULSEN BRIAN PAULSEN2013-06-04
5012009-10-01BRIAN PAULSEN BRIAN PAULSEN2013-06-04
5012008-10-01BRIAN PAULSEN BRIAN PAULSEN2013-06-04
5012007-10-01BRIAN PAULSEN BRIAN PAULSEN2013-06-04
5012006-10-01BRIAN PAULSEN BRIAN PAULSEN2013-06-04
5012005-10-01BRIAN PAULSEN BRIAN PAULSEN2013-06-04

Plan Statistics for STUDENT THERAPY, INC. HEALTH & WELFARE BENEFITS PLAN

401k plan membership statisitcs for STUDENT THERAPY, INC. HEALTH & WELFARE BENEFITS PLAN

Measure Date Value
2021: STUDENT THERAPY, INC. HEALTH & WELFARE BENEFITS PLAN 2021 401k membership
Total participants, beginning-of-year2021-10-01182
Total number of active participants reported on line 7a of the Form 55002021-10-01226
Number of retired or separated participants receiving benefits2021-10-013
Total of all active and inactive participants2021-10-01229
Total participants2021-10-01229
2020: STUDENT THERAPY, INC. HEALTH & WELFARE BENEFITS PLAN 2020 401k membership
Total participants, beginning-of-year2020-10-01192
Total number of active participants reported on line 7a of the Form 55002020-10-01175
Number of retired or separated participants receiving benefits2020-10-017
Number of other retired or separated participants entitled to future benefits2020-10-010
Total of all active and inactive participants2020-10-01182
Total participants2020-10-01182
2019: STUDENT THERAPY, INC. HEALTH & WELFARE BENEFITS PLAN 2019 401k membership
Total participants, beginning-of-year2019-10-01190
Total number of active participants reported on line 7a of the Form 55002019-10-01186
Number of retired or separated participants receiving benefits2019-10-016
Number of other retired or separated participants entitled to future benefits2019-10-010
Total of all active and inactive participants2019-10-01192
Total participants2019-10-01192
2018: STUDENT THERAPY, INC. HEALTH & WELFARE BENEFITS PLAN 2018 401k membership
Total participants, beginning-of-year2018-10-01197
Total number of active participants reported on line 7a of the Form 55002018-10-01190
Total of all active and inactive participants2018-10-01190
Total participants2018-10-01190
2017: STUDENT THERAPY, INC. HEALTH & WELFARE BENEFITS PLAN 2017 401k membership
Total participants, beginning-of-year2017-10-01181
Total number of active participants reported on line 7a of the Form 55002017-10-01194
Number of retired or separated participants receiving benefits2017-10-013
Total of all active and inactive participants2017-10-01197
Total participants2017-10-01197
2016: STUDENT THERAPY, INC. HEALTH & WELFARE BENEFITS PLAN 2016 401k membership
Total participants, beginning-of-year2016-10-01181
Total number of active participants reported on line 7a of the Form 55002016-10-01181
Number of retired or separated participants receiving benefits2016-10-010
Total of all active and inactive participants2016-10-01181
Total participants2016-10-01181
2015: STUDENT THERAPY, INC. HEALTH & WELFARE BENEFITS PLAN 2015 401k membership
Total participants, beginning-of-year2015-10-01153
Total number of active participants reported on line 7a of the Form 55002015-10-01178
Number of retired or separated participants receiving benefits2015-10-013
Total of all active and inactive participants2015-10-01181
Total participants2015-10-01181
2014: STUDENT THERAPY, INC. HEALTH & WELFARE BENEFITS PLAN 2014 401k membership
Total participants, beginning-of-year2014-10-01168
Total number of active participants reported on line 7a of the Form 55002014-10-01151
Number of retired or separated participants receiving benefits2014-10-012
Total of all active and inactive participants2014-10-01153
Total participants2014-10-01153
2013: STUDENT THERAPY, INC. HEALTH & WELFARE BENEFITS PLAN 2013 401k membership
Total participants, beginning-of-year2013-10-01164
Total number of active participants reported on line 7a of the Form 55002013-10-01168
Total of all active and inactive participants2013-10-01168
Total participants2013-10-01168
2012: STUDENT THERAPY, INC. HEALTH & WELFARE BENEFITS PLAN 2012 401k membership
Total participants, beginning-of-year2012-10-01134
Total number of active participants reported on line 7a of the Form 55002012-10-01164
Total of all active and inactive participants2012-10-01164
Total participants2012-10-01164
2011: STUDENT THERAPY, INC. HEALTH & WELFARE BENEFITS PLAN 2011 401k membership
Total participants, beginning-of-year2011-10-01133
Total number of active participants reported on line 7a of the Form 55002011-10-01134
Total of all active and inactive participants2011-10-01134
Total participants2011-10-01134
2009: STUDENT THERAPY, INC. HEALTH & WELFARE BENEFITS PLAN 2009 401k membership
Total participants, beginning-of-year2009-10-01110
Total number of active participants reported on line 7a of the Form 55002009-10-01106
Total of all active and inactive participants2009-10-01106
Total participants2009-10-01106
2008: STUDENT THERAPY, INC. HEALTH & WELFARE BENEFITS PLAN 2008 401k membership
Total participants, beginning-of-year2008-10-01152
Total number of active participants reported on line 7a of the Form 55002008-10-01110
Total of all active and inactive participants2008-10-01110
Total participants2008-10-01110
2007: STUDENT THERAPY, INC. HEALTH & WELFARE BENEFITS PLAN 2007 401k membership
Total participants, beginning-of-year2007-10-01152
Total number of active participants reported on line 7a of the Form 55002007-10-01152
Total of all active and inactive participants2007-10-01152
Total participants2007-10-01152
2006: STUDENT THERAPY, INC. HEALTH & WELFARE BENEFITS PLAN 2006 401k membership
Total participants, beginning-of-year2006-10-01114
Total number of active participants reported on line 7a of the Form 55002006-10-01152
Total of all active and inactive participants2006-10-01152
Total participants2006-10-01152
2005: STUDENT THERAPY, INC. HEALTH & WELFARE BENEFITS PLAN 2005 401k membership
Total participants, beginning-of-year2005-10-01109
Total number of active participants reported on line 7a of the Form 55002005-10-01114
Total of all active and inactive participants2005-10-01114
Total participants2005-10-01114

Form 5500 Responses for STUDENT THERAPY, INC. HEALTH & WELFARE BENEFITS PLAN

2021: STUDENT THERAPY, INC. HEALTH & WELFARE BENEFITS PLAN 2021 form 5500 responses
2021-10-01Type of plan entitySingle employer plan
2021-10-01Submission has been amendedNo
2021-10-01This submission is the final filingNo
2021-10-01This return/report is a short plan year return/report (less than 12 months)No
2021-10-01Plan is a collectively bargained planNo
2021-10-01Plan funding arrangement – InsuranceYes
2021-10-01Plan benefit arrangement – InsuranceYes
2020: STUDENT THERAPY, INC. HEALTH & WELFARE BENEFITS PLAN 2020 form 5500 responses
2020-10-01Type of plan entitySingle employer plan
2020-10-01Submission has been amendedNo
2020-10-01This submission is the final filingNo
2020-10-01This return/report is a short plan year return/report (less than 12 months)No
2020-10-01Plan is a collectively bargained planNo
2020-10-01Plan funding arrangement – InsuranceYes
2020-10-01Plan funding arrangement – General assets of the sponsorYes
2020-10-01Plan benefit arrangement – InsuranceYes
2020-10-01Plan benefit arrangement – General assets of the sponsorYes
2019: STUDENT THERAPY, INC. HEALTH & WELFARE BENEFITS PLAN 2019 form 5500 responses
2019-10-01Type of plan entitySingle employer plan
2019-10-01Submission has been amendedNo
2019-10-01This submission is the final filingNo
2019-10-01This return/report is a short plan year return/report (less than 12 months)No
2019-10-01Plan is a collectively bargained planNo
2019-10-01Plan funding arrangement – InsuranceYes
2019-10-01Plan funding arrangement – General assets of the sponsorYes
2019-10-01Plan benefit arrangement – InsuranceYes
2019-10-01Plan benefit arrangement – General assets of the sponsorYes
2018: STUDENT THERAPY, INC. HEALTH & WELFARE BENEFITS PLAN 2018 form 5500 responses
2018-10-01Type of plan entitySingle employer plan
2018-10-01Submission has been amendedNo
2018-10-01This submission is the final filingNo
2018-10-01This return/report is a short plan year return/report (less than 12 months)No
2018-10-01Plan is a collectively bargained planNo
2018-10-01Plan funding arrangement – InsuranceYes
2018-10-01Plan benefit arrangement – InsuranceYes
2017: STUDENT THERAPY, INC. HEALTH & WELFARE BENEFITS PLAN 2017 form 5500 responses
2017-10-01Type of plan entitySingle employer plan
2017-10-01Submission has been amendedNo
2017-10-01This submission is the final filingNo
2017-10-01This return/report is a short plan year return/report (less than 12 months)No
2017-10-01Plan is a collectively bargained planNo
2017-10-01Plan funding arrangement – InsuranceYes
2017-10-01Plan benefit arrangement – InsuranceYes
2016: STUDENT THERAPY, INC. HEALTH & WELFARE BENEFITS PLAN 2016 form 5500 responses
2016-10-01Type of plan entitySingle employer plan
2016-10-01Submission has been amendedNo
2016-10-01This submission is the final filingNo
2016-10-01This return/report is a short plan year return/report (less than 12 months)No
2016-10-01Plan is a collectively bargained planNo
2016-10-01Plan funding arrangement – InsuranceYes
2016-10-01Plan benefit arrangement – InsuranceYes
2015: STUDENT THERAPY, INC. HEALTH & WELFARE BENEFITS PLAN 2015 form 5500 responses
2015-10-01Type of plan entitySingle employer plan
2015-10-01Submission has been amendedNo
2015-10-01This submission is the final filingNo
2015-10-01This return/report is a short plan year return/report (less than 12 months)No
2015-10-01Plan is a collectively bargained planNo
2015-10-01Plan funding arrangement – InsuranceYes
2015-10-01Plan benefit arrangement – InsuranceYes
2014: STUDENT THERAPY, INC. HEALTH & WELFARE BENEFITS PLAN 2014 form 5500 responses
2014-10-01Type of plan entitySingle employer plan
2014-10-01Submission has been amendedNo
2014-10-01This submission is the final filingNo
2014-10-01This return/report is a short plan year return/report (less than 12 months)No
2014-10-01Plan is a collectively bargained planNo
2014-10-01Plan funding arrangement – InsuranceYes
2014-10-01Plan benefit arrangement – InsuranceYes
2013: STUDENT THERAPY, INC. HEALTH & WELFARE BENEFITS PLAN 2013 form 5500 responses
2013-10-01Type of plan entitySingle employer plan
2013-10-01Submission has been amendedNo
2013-10-01This submission is the final filingNo
2013-10-01This return/report is a short plan year return/report (less than 12 months)No
2013-10-01Plan is a collectively bargained planNo
2013-10-01Plan funding arrangement – InsuranceYes
2013-10-01Plan benefit arrangement – InsuranceYes
2012: STUDENT THERAPY, INC. HEALTH & WELFARE BENEFITS PLAN 2012 form 5500 responses
2012-10-01Type of plan entitySingle employer plan
2012-10-01Submission has been amendedNo
2012-10-01This submission is the final filingNo
2012-10-01This return/report is a short plan year return/report (less than 12 months)No
2012-10-01Plan is a collectively bargained planNo
2012-10-01Plan funding arrangement – InsuranceYes
2012-10-01Plan benefit arrangement – InsuranceYes
2011: STUDENT THERAPY, INC. HEALTH & WELFARE BENEFITS PLAN 2011 form 5500 responses
2011-10-01Type of plan entitySingle employer plan
2011-10-01Submission has been amendedNo
2011-10-01This submission is the final filingNo
2011-10-01This return/report is a short plan year return/report (less than 12 months)No
2011-10-01Plan is a collectively bargained planNo
2011-10-01Plan funding arrangement – InsuranceYes
2011-10-01Plan benefit arrangement – InsuranceYes
2009: STUDENT THERAPY, INC. HEALTH & WELFARE BENEFITS PLAN 2009 form 5500 responses
2009-10-01Type of plan entitySingle employer plan
2009-10-01Submission has been amendedNo
2009-10-01This submission is the final filingNo
2009-10-01This return/report is a short plan year return/report (less than 12 months)No
2009-10-01Plan is a collectively bargained planNo
2009-10-01Plan funding arrangement – InsuranceYes
2009-10-01Plan benefit arrangement – InsuranceYes
2008: STUDENT THERAPY, INC. HEALTH & WELFARE BENEFITS PLAN 2008 form 5500 responses
2008-10-01Type of plan entitySingle employer plan
2008-10-01Submission has been amendedNo
2008-10-01This submission is the final filingNo
2008-10-01This return/report is a short plan year return/report (less than 12 months)No
2008-10-01Plan is a collectively bargained planNo
2008-10-01Plan funding arrangement – InsuranceYes
2008-10-01Plan benefit arrangement – InsuranceYes
2007: STUDENT THERAPY, INC. HEALTH & WELFARE BENEFITS PLAN 2007 form 5500 responses
2007-10-01Type of plan entitySingle employer plan
2007-10-01Submission has been amendedNo
2007-10-01This submission is the final filingNo
2007-10-01This return/report is a short plan year return/report (less than 12 months)No
2007-10-01Plan is a collectively bargained planNo
2007-10-01Plan funding arrangement – InsuranceYes
2007-10-01Plan benefit arrangement – InsuranceYes
2006: STUDENT THERAPY, INC. HEALTH & WELFARE BENEFITS PLAN 2006 form 5500 responses
2006-10-01Type of plan entitySingle employer plan
2006-10-01Submission has been amendedNo
2006-10-01This submission is the final filingNo
2006-10-01This return/report is a short plan year return/report (less than 12 months)No
2006-10-01Plan is a collectively bargained planNo
2006-10-01Plan funding arrangement – InsuranceYes
2006-10-01Plan benefit arrangement – InsuranceYes
2005: STUDENT THERAPY, INC. HEALTH & WELFARE BENEFITS PLAN 2005 form 5500 responses
2005-10-01Type of plan entitySingle employer plan
2005-10-01First time form 5500 has been submittedYes
2005-10-01Submission has been amendedNo
2005-10-01This submission is the final filingNo
2005-10-01This return/report is a short plan year return/report (less than 12 months)No
2005-10-01Plan is a collectively bargained planNo
2005-10-01Plan funding arrangement – InsuranceYes
2005-10-01Plan benefit arrangement – InsuranceYes

Insurance Providers Used on plan

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number10183841001
Policy instance 3
Insurance contract or identification number10183841001
Number of Individuals Covered271
Insurance policy start date2021-10-01
Insurance policy end date2022-09-30
Total amount of commissions paid to insurance brokerUSD $1,325
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 planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $13,678
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,325
BLUE CROSS BLUE SHIELD OF ARIZONA (National Association of Insurance Commissioners NAIC id number: 53589 )
Policy contract number040808
Policy instance 2
Insurance contract or identification number040808
Number of Individuals Covered285
Insurance policy start date2021-10-01
Insurance policy end date2022-09-30
Total amount of commissions paid to insurance brokerUSD $57,604
Total amount of fees paid to insurance companyUSD $600
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 planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $1,192,677
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $57,604
Amount paid for insurance broker fees600
Additional information about fees paid to insurance broker1*SPECIAL INCENTIVE
Insurance broker organization code?5
MONY (National Association of Insurance Commissioners NAIC id number: 78077 )
Policy contract number010926
Policy instance 1
Insurance contract or identification number010926
Number of Individuals Covered226
Insurance policy start date2021-10-01
Insurance policy end date2022-09-30
Total amount of commissions paid to insurance brokerUSD $881
Total amount of fees paid to insurance companyUSD $403
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 planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&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 CarrierUSD $6,489
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Amount paid for insurance broker fees294
Additional information about fees paid to insurance broker4*BONUS
Insurance broker organization code?3
Commission paid to Insurance BrokerUSD $881
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberSGM610219
Policy instance 1
Insurance contract or identification numberSGM610219
Insurance policy start date2020-10-01
Insurance policy end date2021-09-30
Total amount of commissions paid to insurance brokerUSD $606
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&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 CarrierUSD $4,041
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $606
Amount paid for insurance broker fees0
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number00626967
Policy instance 2
Insurance contract or identification number00626967
Number of Individuals Covered194
Insurance policy start date2020-10-01
Insurance policy end date2021-09-30
Total amount of commissions paid to insurance brokerUSD $48,620
Total amount of fees paid to insurance companyUSD $26,355
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 planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $274,830
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $48,620
Amount paid for insurance broker fees26355
Additional information about fees paid to insurance brokerSERVICE AND/OR GENERAL AGENT FEE INCENTIVE COMPENSATION PAYMENTS
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number10183841001
Policy instance 3
Insurance contract or identification number10183841001
Number of Individuals Covered215
Insurance policy start date2020-10-01
Insurance policy end date2021-09-30
Total amount of commissions paid to insurance brokerUSD $1,382
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $12,725
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $115
Amount paid for insurance broker fees0
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number00626967
Policy instance 3
Insurance contract or identification number00626967
Number of Individuals Covered210
Insurance policy start date2019-10-01
Insurance policy end date2020-09-30
Total amount of commissions paid to insurance brokerUSD $57,414
Total amount of fees paid to insurance companyUSD $23,100
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 planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $274,694
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $0
Amount paid for insurance broker fees23100
Additional information about fees paid to insurance brokerSERVICE AND/OR GENERAL AGENT FEE
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberSGM610219
Policy instance 2
Insurance contract or identification numberSGM610219
Insurance policy start date2019-10-01
Insurance policy end date2020-09-30
Total amount of commissions paid to insurance brokerUSD $659
Total amount of fees paid to insurance companyUSD $210
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 planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&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 CarrierUSD $4,390
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $659
Amount paid for insurance broker fees210
Additional information about fees paid to insurance brokerOVERRIDE
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number10183841001
Policy instance 1
Insurance contract or identification number10183841001
Number of Individuals Covered235
Insurance policy start date2019-10-01
Insurance policy end date2020-09-30
Total amount of commissions paid to insurance brokerUSD $1,382
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 planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $13,823
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $1,382
Amount paid for insurance broker fees0
MONY (National Association of Insurance Commissioners NAIC id number: 78077 )
Policy contract number002426
Policy instance 1
Insurance contract or identification number002426
Number of Individuals Covered190
Insurance policy start date2018-10-01
Insurance policy end date2019-10-01
Total amount of commissions paid to insurance brokerUSD $459
Total amount of fees paid to insurance companyUSD $228
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 planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&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 CarrierUSD $3,059
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $459
Insurance broker organization code?3
Amount paid for insurance broker fees228
Additional information about fees paid to insurance brokerSERVICE FEE AND BONUS
BLUE CROSS BLUE SHIELD OF ARIZONA (National Association of Insurance Commissioners NAIC id number: 53589 )
Policy contract number36333
Policy instance 2
Insurance contract or identification number36333
Number of Individuals Covered182
Insurance policy start date2018-10-01
Insurance policy end date2019-09-30
Total amount of commissions paid to insurance brokerUSD $56,945
Total amount of fees paid to insurance companyUSD $7,917
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 planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $1,178,630
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $56,945
Amount paid for insurance broker fees7917
Additional information about fees paid to insurance brokerSPECIAL INCENTIVE
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number10183841001
Policy instance 3
Insurance contract or identification number10183841001
Number of Individuals Covered247
Insurance policy start date2018-10-01
Insurance policy end date2019-09-30
Total amount of commissions paid to insurance brokerUSD $1,255
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 planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $13,696
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,255
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number909124
Policy instance 1
Insurance contract or identification number909124
Number of Individuals Covered287
Insurance policy start date2017-10-01
Insurance policy end date2018-09-30
Total amount of commissions paid to insurance brokerUSD $5,582
Total amount of fees paid to insurance companyUSD $68,215
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 planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $1,287,905
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number00516798
Policy instance 3
Insurance contract or identification number00516798
Number of Individuals Covered179
Insurance policy start date2015-10-01
Insurance policy end date2016-09-30
Total amount of commissions paid to insurance brokerUSD $8,559
Total amount of fees paid to insurance companyUSD $604
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&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 CarrierUSD $86,005
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $8,559
Amount paid for insurance broker fees604
Insurance broker organization code?3
Insurance broker nameBENEFIT COMMERCE GROUP
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number00611822
Policy instance 1
Insurance contract or identification number00611822
Number of Individuals Covered158
Insurance policy start date2015-01-01
Insurance policy end date2015-12-31
Total amount of commissions paid to insurance brokerUSD $39,219
Total amount of fees paid to insurance companyUSD $14,185
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $267,889
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $0
Amount paid for insurance broker fees14185
Additional information about fees paid to insurance brokerSERVICE FEES
Insurance broker organization code?3
Insurance broker nameBENEFIT COMMERCE GROUP
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number0773412
Policy instance 2
Insurance contract or identification number0773412
Number of Individuals Covered216
Insurance policy start date2015-10-01
Insurance policy end date2016-09-30
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $5,000
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $1,058,737
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $0
Amount paid for insurance broker fees5000
Additional information about fees paid to insurance brokerNEW SALES INCENTIVE
Insurance broker organization code?3
Insurance broker nameBENEFIT COMMERCE GROUP
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number00611822
Policy instance 2
Insurance contract or identification number00611822
Number of Individuals Covered135
Insurance policy start date2014-01-01
Insurance policy end date2014-12-31
Total amount of commissions paid to insurance brokerUSD $11,286
Total amount of fees paid to insurance companyUSD $4,514
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $66,116
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Amount paid for insurance broker fees4514
Additional information about fees paid to insurance brokerGENERAL AGENT FEE
Insurance broker organization code?3
Commission paid to Insurance BrokerUSD $11,286
Insurance broker nameBENEFIT COMMERCE GROUP
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract numberKM05994932
Policy instance 1
Insurance contract or identification numberKM05994932
Number of Individuals Covered162
Insurance policy start date2014-10-01
Insurance policy end date2015-09-30
Total amount of commissions paid to insurance brokerUSD $255
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&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 CarrierUSD $1,741
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $255
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameBENEFIT COMMERCE GROUP
BLUE CROSS BLUE SHIELD OF ARIZONA (National Association of Insurance Commissioners NAIC id number: 53589 )
Policy contract number019980
Policy instance 2
Insurance contract or identification number019980
Number of Individuals Covered128
Insurance policy start date2013-10-01
Insurance policy end date2014-09-30
Total amount of commissions paid to insurance brokerUSD $48,275
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $48,275
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameANGELONE & ASSOCIATES INC
DENTAL MANAGEMENT ADMINISTRATORS (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract numberAXT AZP52008
Policy instance 3
Insurance contract or identification numberAXT AZP52008
Number of Individuals Covered189
Insurance policy start date2013-10-01
Insurance policy end date2014-09-30
Total amount of commissions paid to insurance brokerUSD $5,376
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $68,504
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,688
Insurance broker organization code?3
Insurance broker nameCSA GENERAL INSURANCE AGENCY
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract numberKM05994932
Policy instance 1
Insurance contract or identification numberKM05994932
Number of Individuals Covered144
Insurance policy start date2013-10-01
Insurance policy end date2014-09-30
Total amount of commissions paid to insurance brokerUSD $229
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&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 CarrierUSD $1,374
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $229
Insurance broker organization code?3
Insurance broker nameBENEFIT COMMERCE GROUP
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract numberKM05994932
Policy instance 3
Insurance contract or identification numberKM05994932
Number of Individuals Covered144
Insurance policy start date2012-10-01
Insurance policy end date2013-09-30
Total amount of commissions paid to insurance brokerUSD $177
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&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 CarrierUSD $1,458
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $177
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameBENEFIT COMMERCE GROUP
COMPANION LIFE (National Association of Insurance Commissioners NAIC id number: 77828 )
Policy contract numberAXT AZP52008
Policy instance 2
Insurance contract or identification numberAXT AZP52008
Number of Individuals Covered181
Insurance policy start date2012-10-01
Insurance policy end date2013-09-30
Total amount of commissions paid to insurance brokerUSD $4,574
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $55,019
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,287
Insurance broker organization code?3
Insurance broker nameBENEFIT COMMERCE GROUP
BLUE CROSS BLUE SHIELD OF ARIZONA (National Association of Insurance Commissioners NAIC id number: 53589 )
Policy contract number19980
Policy instance 1
Insurance contract or identification number19980
Number of Individuals Covered133
Insurance policy start date2012-10-01
Insurance policy end date2013-09-30
Total amount of commissions paid to insurance brokerUSD $40,786
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $40,786
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameANGELONE & ASSOCIATES
DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 )
Policy contract numberA019980
Policy instance 3
Insurance contract or identification numberA019980
Insurance policy start date2011-10-01
Insurance policy end date2012-09-30
Total amount of commissions paid to insurance brokerUSD $2,728
Life Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $68,209
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
COMPANION LIFE (National Association of Insurance Commissioners NAIC id number: 77828 )
Policy contract numberAXT AZP52008
Policy instance 2
Insurance contract or identification numberAXT AZP52008
Number of Individuals Covered174
Insurance policy start date2011-10-01
Insurance policy end date2012-09-30
Total amount of commissions paid to insurance brokerUSD $2,847
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $67,088
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 number19980
Policy instance 1
Insurance contract or identification number19980
Number of Individuals Covered123
Insurance policy start date2011-10-01
Insurance policy end date2012-09-30
Total amount of commissions paid to insurance brokerUSD $43,601
Total amount of fees paid to insurance companyUSD $150
Health Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Welfare Benefit Premiums Paid to CarrierUSD $732,096
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 )
Policy contract numberA019980
Policy instance 3
Insurance contract or identification numberA019980
Insurance policy start date2010-10-01
Insurance policy end date2011-09-30
Total amount of commissions paid to insurance brokerUSD $4,637
Life Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $57,964
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
COMPANION LIFE (National Association of Insurance Commissioners NAIC id number: 77828 )
Policy contract numberAXT AZP52008
Policy instance 2
Insurance contract or identification numberAXT AZP52008
Number of Individuals Covered184
Insurance policy start date2010-10-01
Insurance policy end date2011-09-30
Total amount of commissions paid to insurance brokerUSD $4,652
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $59,085
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 number19980
Policy instance 1
Insurance contract or identification number19980
Number of Individuals Covered129
Insurance policy start date2010-10-01
Insurance policy end date2011-09-30
Total amount of commissions paid to insurance brokerUSD $37,256
Health Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 )
Policy contract numberA019980
Policy instance 1
Insurance contract or identification numberA019980
Insurance policy start date2008-10-01
Insurance policy end date2009-09-30
Life Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
BLUE CROSS BLUE SHIELD OF ARIZONA (National Association of Insurance Commissioners NAIC id number: 53589 )
Policy contract number19980
Policy instance 2
Insurance contract or identification number19980
Number of Individuals Covered114
Insurance policy start date2008-10-01
Insurance policy end date2009-09-30
Total amount of commissions paid to insurance brokerUSD $40,872
Health Insurance Welfare BenefitYes
Were dividends or retroactive rate refunds paid in cash?Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $40,872
Insurance broker organization code?3
Insurance broker nameDORN AGENCY INC
COMPANION LIFE (National Association of Insurance Commissioners NAIC id number: 77828 )
Policy contract numberAXT AZP52008
Policy instance 3
Insurance contract or identification numberAXT AZP52008
Number of Individuals Covered160
Insurance policy start date2008-10-01
Insurance policy end date2009-09-30
Total amount of commissions paid to insurance brokerUSD $6,079
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $67,056
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6,079
Insurance broker organization code?3
Insurance broker nameBLACK, GOULD & ASSOCIATES
COMPANION LIFE (National Association of Insurance Commissioners NAIC id number: 77828 )
Policy contract numberAXT AZP52008
Policy instance 3
Insurance contract or identification numberAXT AZP52008
Number of Individuals Covered215
Insurance policy start date2007-10-01
Insurance policy end date2008-09-30
Total amount of commissions paid to insurance brokerUSD $5,277
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $79,114
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,277
Insurance broker organization code?3
Insurance broker nameBLACK, GOULD & ASSOCIATES
DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 )
Policy contract numberA019980
Policy instance 2
Insurance contract or identification numberA019980
Insurance policy start date2007-10-01
Insurance policy end date2008-09-30
Life Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
BLUE CROSS BLUE SHIELD OF ARIZONA (National Association of Insurance Commissioners NAIC id number: 53589 )
Policy contract number19980
Policy instance 1
Insurance contract or identification number19980
Number of Individuals Covered157
Insurance policy start date2007-10-01
Insurance policy end date2008-09-30
Total amount of commissions paid to insurance brokerUSD $38,530
Health Insurance Welfare BenefitYes
Were dividends or retroactive rate refunds paid in cash?Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $38,530
Insurance broker organization code?3
Insurance broker nameDORN AGENCY INC
BLUE CROSS BLUE SHIELD OF ARIZONA (National Association of Insurance Commissioners NAIC id number: 53589 )
Policy contract number19980
Policy instance 1
Insurance contract or identification number19980
Number of Individuals Covered151
Insurance policy start date2006-10-01
Insurance policy end date2007-09-30
Total amount of commissions paid to insurance brokerUSD $24,980
Health Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $24,980
Insurance broker organization code?3
Insurance broker nameDORN AGENCY INC
COMPANION LIFE (National Association of Insurance Commissioners NAIC id number: 77828 )
Policy contract numberAXT AZP52008
Policy instance 2
Insurance contract or identification numberAXT AZP52008
Number of Individuals Covered208
Insurance policy start date2006-10-01
Insurance policy end date2007-09-30
Total amount of commissions paid to insurance brokerUSD $4,832
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $56,475
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,832
Insurance broker organization code?3
Insurance broker nameBLACK, GOULD & ASSOCIATES
DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 )
Policy contract numberA019980
Policy instance 3
Insurance contract or identification numberA019980
Insurance policy start date2006-10-01
Insurance policy end date2007-09-30
Life Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 )
Policy contract numberA019980
Policy instance 3
Insurance contract or identification numberA019980
Insurance policy start date2005-10-01
Insurance policy end date2006-09-30
Life Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
COMPANION LIFE (National Association of Insurance Commissioners NAIC id number: 77828 )
Policy contract numberAXT AZP52008
Policy instance 2
Insurance contract or identification numberAXT AZP52008
Number of Individuals Covered145
Insurance policy start date2005-10-01
Insurance policy end date2006-09-30
Total amount of commissions paid to insurance brokerUSD $3,693
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $52,358
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,693
Insurance broker organization code?3
Insurance broker nameBLACK, GOULD & ASSOCIATES
BLUE CROSS BLUE SHIELD OF ARIZONA (National Association of Insurance Commissioners NAIC id number: 53589 )
Policy contract number19980
Policy instance 1
Insurance contract or identification number19980
Number of Individuals Covered123
Insurance policy start date2005-10-01
Insurance policy end date2006-09-30
Total amount of commissions paid to insurance brokerUSD $27,677
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $516,918
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $27,677
Insurance broker organization code?3
Insurance broker nameDORN AGENCY INC

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