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UTAH IMAGING ASSOCIATES, INC. 401(K) PROFIT SHARING PLAN 401k Plan overview

Plan NameUTAH IMAGING ASSOCIATES, INC. 401(K) PROFIT SHARING PLAN
Plan identification number 002

UTAH IMAGING ASSOCIATES, INC. 401(K) PROFIT SHARING PLAN Benefits

401k Plan TypeDefined Contribution Pension
Plan Features/Benefits
  • Age/Service Weighted or new comparability or similar plan - Age/Service Weighted Plan: Allocations are based on age, service, or age and service. New comparability or similar plan: Allocations are based on participant classifications and a classification(s) consists entirely or predominantly of highly compensated employees; or the plan provides an additional allocation rate on compensation above a specified threshold, and the theshold or additional rate exceeds the maximum threshold or rate allowed under the permitted disparity rules of section 401(l).
  • Profit-sharing
  • ERISA section 404(c) Plan - This plan, or any part of it is intended to meet the conditions of 29 CFR 2550.404c-1.
  • Total participant-directed account plan - Participants have the opportunity to direct the investment of all the assets allocated to their individual accounts, regardless of whether 29 CFR 2550.404c-1 is intended to be met.
  • Code section 401(k) feature - A cash or deferred arrangement described in Code section 401(k) that is part of a qualified defined contribution plan that provides for an election by employees to defer part of their compensation or receive these amounts in cash.
  • Code section 401(m) arrangement - Employee contributions are allocated to separate accounts under the plan or employer contributions are based, in whole or in part, on employee deferrals or contribtions to the plan. Not applicable if plan is 401(k) plan with only QNECs and/or QMACs. Also not applicable if Code section 403(b)(1), 403(b)(7) or 408 arrangements/accounts/annuities.
  • Participant-directed brokerage accounts provided as an investment option under the plan.
  • Total or partial participant-directed account plan - plan uses default investment account for participants who fail to direct assets in their account.
  • Master plan - A pension plan that is made available by a sponsor for adoption by employers; that is the subject of a favorable opinion letter; and for which a single funding medium (for example, a trust or custodial account) is established for the joint use of all adopting employers.

401k Sponsoring company profile

UTAH IMAGING ASSOCIATES, INC. has sponsored the creation of one or more 401k plans.

Company Name:UTAH IMAGING ASSOCIATES, INC.
Employer identification number (EIN):870622942
NAIC Classification:621111
NAIC Description:Offices of Physicians (except Mental Health Specialists)

Form 5500 Filing Information

Submission information for form 5500 for 401k plan UTAH IMAGING ASSOCIATES, INC. 401(K) PROFIT SHARING PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
0022022-01-01JASON KIRKHAM2023-10-03
0022021-01-01
0022020-01-01
0022019-01-01
0022018-01-01
0022017-01-01PATRICIA A. HARMS2018-10-11
0022016-01-01PATRICIA A. HARMS2017-09-14
0022015-01-01BRETT PALMER2016-10-04 BRETT PALMER2016-10-04
0022014-01-01BRETT PALMER2015-10-05 BRETT PALMER2015-10-05
0022013-01-01BRETT PALMER BRETT PALMER2014-10-10
0022012-01-01BRETT PALMER BRETT PALMER2013-12-13
0022011-01-01BRETT PALMER BRETT PALMER2012-09-25
0022009-01-01BRETT PALMER BRETT PALMER2010-11-11
0022009-01-01BRETT PALMER BRETT PALMER2010-10-13

Plan Statistics for UTAH IMAGING ASSOCIATES, INC. 401(K) PROFIT SHARING PLAN

401k plan membership statisitcs for UTAH IMAGING ASSOCIATES, INC. 401(K) PROFIT SHARING PLAN

Measure Date Value
2022: UTAH IMAGING ASSOCIATES, INC. 401(K) PROFIT SHARING PLAN 2022 401k membership
Total participants, beginning-of-year2022-01-0151
Total number of active participants reported on line 7a of the Form 55002022-01-0137
Number of retired or separated participants receiving benefits2022-01-010
Number of other retired or separated participants entitled to future benefits2022-01-0119
Total of all active and inactive participants2022-01-0156
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits2022-01-010
Total participants2022-01-0156
Number of participants with account balances2022-01-0156
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested2022-01-013
2013: UTAH IMAGING ASSOCIATES, INC. 401(K) PROFIT SHARING PLAN 2013 401k membership
Total participants, beginning-of-year2013-01-0137
Total number of active participants reported on line 7a of the Form 55002013-01-0127
Number of retired or separated participants receiving benefits2013-01-010
Number of other retired or separated participants entitled to future benefits2013-01-019
Total of all active and inactive participants2013-01-0136
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits2013-01-010
Total participants2013-01-0136
Number of participants with account balances2013-01-0136
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested2013-01-011
2012: UTAH IMAGING ASSOCIATES, INC. 401(K) PROFIT SHARING PLAN 2012 401k membership
Total participants, beginning-of-year2012-01-0139
Total number of active participants reported on line 7a of the Form 55002012-01-0128
Number of retired or separated participants receiving benefits2012-01-010
Number of other retired or separated participants entitled to future benefits2012-01-019
Total of all active and inactive participants2012-01-0137
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits2012-01-010
Total participants2012-01-0137
Number of participants with account balances2012-01-0137
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested2012-01-010
2011: UTAH IMAGING ASSOCIATES, INC. 401(K) PROFIT SHARING PLAN 2011 401k membership
Total participants, beginning-of-year2011-01-0146
Total number of active participants reported on line 7a of the Form 55002011-01-0127
Number of retired or separated participants receiving benefits2011-01-010
Number of other retired or separated participants entitled to future benefits2011-01-0112
Total of all active and inactive participants2011-01-0139
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits2011-01-010
Total participants2011-01-0139
Number of participants with account balances2011-01-0139
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested2011-01-010
2009: UTAH IMAGING ASSOCIATES, INC. 401(K) PROFIT SHARING PLAN 2009 401k membership
Total participants, beginning-of-year2009-01-0144
Total number of active participants reported on line 7a of the Form 55002009-01-0130
Number of retired or separated participants receiving benefits2009-01-010
Number of other retired or separated participants entitled to future benefits2009-01-0113
Total of all active and inactive participants2009-01-0143
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits2009-01-010
Total participants2009-01-0143
Number of participants with account balances2009-01-0143
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested2009-01-010

Financial Data on UTAH IMAGING ASSOCIATES, INC. 401(K) PROFIT SHARING PLAN

Measure Date Value
2022 : UTAH IMAGING ASSOCIATES, INC. 401(K) PROFIT SHARING PLAN 2022 401k financial data
Transfers to/from the plan2022-12-31$0
Total income from all sources2022-12-31$-202,461
Expenses. Total of all expenses incurred2022-12-31$5,331,013
Benefits paid (including direct rollovers)2022-12-31$5,290,894
Total plan assets at end of year2022-12-31$14,657,681
Total plan assets at beginning of year2022-12-31$20,191,155
Value of fidelity bond covering the plan2022-12-31$500,000
Total contributions received or receivable from participants2022-12-31$117,624
Assets. Value of loans (other than to participants)2022-12-31$106,597
Contributions received from other sources (not participants or employers)2022-12-31$204,506
Other income received2022-12-31$-1,997,017
Net income (gross income less expenses)2022-12-31$-5,533,474
Net plan assets at end of year (total assets less liabilities)2022-12-31$14,657,681
Net plan assets at beginning of year (total assets less liabilities)2022-12-31$20,191,155
Assets. Value of participant loans2022-12-31$7,275
Total contributions received or receivable from employer(s)2022-12-31$1,472,426
Expenses. Administrative service providers (salaries,fees and commissions)2022-12-31$40,119
2013 : UTAH IMAGING ASSOCIATES, INC. 401(K) PROFIT SHARING PLAN 2013 401k financial data
Total plan liabilities at end of year2013-12-31$0
Total plan liabilities at beginning of year2013-12-31$0
Total income from all sources2013-12-31$3,948,332
Expenses. Total of all expenses incurred2013-12-31$961,731
Benefits paid (including direct rollovers)2013-12-31$961,731
Total plan assets at end of year2013-12-31$21,002,065
Total plan assets at beginning of year2013-12-31$18,015,464
Value of fidelity bond covering the plan2013-12-31$1,000,000
Total contributions received or receivable from participants2013-12-31$8,500
Contributions received from other sources (not participants or employers)2013-12-31$3,468
Other income received2013-12-31$2,685,742
Net income (gross income less expenses)2013-12-31$2,986,601
Net plan assets at end of year (total assets less liabilities)2013-12-31$21,002,065
Net plan assets at beginning of year (total assets less liabilities)2013-12-31$18,015,464
Assets. Value of participant loans2013-12-31$35,510
Assets. Value of assets in partnership/joint-venture interests2013-12-31$143,283
Total contributions received or receivable from employer(s)2013-12-31$1,250,622
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities2013-12-31$0
2012 : UTAH IMAGING ASSOCIATES, INC. 401(K) PROFIT SHARING PLAN 2012 401k financial data
Total plan liabilities at end of year2012-12-31$0
Total plan liabilities at beginning of year2012-12-31$0
Total income from all sources2012-12-31$3,850,289
Expenses. Total of all expenses incurred2012-12-31$10,127,591
Benefits paid (including direct rollovers)2012-12-31$10,127,591
Total plan assets at end of year2012-12-31$18,002,964
Total plan assets at beginning of year2012-12-31$24,280,266
Value of fidelity bond covering the plan2012-12-31$1,000,000
Total contributions received or receivable from participants2012-12-31$11,000
Contributions received from other sources (not participants or employers)2012-12-31$615,137
Other income received2012-12-31$1,944,036
Net income (gross income less expenses)2012-12-31$-6,277,302
Net plan assets at end of year (total assets less liabilities)2012-12-31$18,002,964
Net plan assets at beginning of year (total assets less liabilities)2012-12-31$24,280,266
Assets. Value of participant loans2012-12-31$44,881
Assets. Value of assets in partnership/joint-venture interests2012-12-31$2,267
Total contributions received or receivable from employer(s)2012-12-31$1,280,116
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities2012-12-31$0
2011 : UTAH IMAGING ASSOCIATES, INC. 401(K) PROFIT SHARING PLAN 2011 401k financial data
Total plan liabilities at end of year2011-12-31$0
Total plan liabilities at beginning of year2011-12-31$0
Total income from all sources2011-12-31$1,720,216
Expenses. Total of all expenses incurred2011-12-31$2,511,183
Benefits paid (including direct rollovers)2011-12-31$2,511,183
Total plan assets at end of year2011-12-31$24,280,266
Total plan assets at beginning of year2011-12-31$25,071,233
Value of fidelity bond covering the plan2011-12-31$1,000,000
Total contributions received or receivable from participants2011-12-31$13,750
Contributions received from other sources (not participants or employers)2011-12-31$95,131
Other income received2011-12-31$362,410
Net income (gross income less expenses)2011-12-31$-790,967
Net plan assets at end of year (total assets less liabilities)2011-12-31$24,280,266
Net plan assets at beginning of year (total assets less liabilities)2011-12-31$25,071,233
Assets. Value of participant loans2011-12-31$13,424
Assets. Value of assets in partnership/joint-venture interests2011-12-31$97,605
Total contributions received or receivable from employer(s)2011-12-31$1,248,925
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities2011-12-31$0
2010 : UTAH IMAGING ASSOCIATES, INC. 401(K) PROFIT SHARING PLAN 2010 401k financial data
Total plan liabilities at end of year2010-12-31$0
Total plan liabilities at beginning of year2010-12-31$0
Total income from all sources2010-12-31$5,317,175
Expenses. Total of all expenses incurred2010-12-31$5,073,723
Benefits paid (including direct rollovers)2010-12-31$5,073,723
Total plan assets at end of year2010-12-31$25,071,233
Total plan assets at beginning of year2010-12-31$24,827,781
Value of fidelity bond covering the plan2010-12-31$1,000,000
Total contributions received or receivable from participants2010-12-31$27,500
Contributions received from other sources (not participants or employers)2010-12-31$459,946
Other income received2010-12-31$3,443,601
Net income (gross income less expenses)2010-12-31$243,452
Net plan assets at end of year (total assets less liabilities)2010-12-31$25,071,233
Net plan assets at beginning of year (total assets less liabilities)2010-12-31$24,827,781
Assets. Value of assets in partnership/joint-venture interests2010-12-31$638,318
Total contributions received or receivable from employer(s)2010-12-31$1,386,128
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities2010-12-31$0
2009 : UTAH IMAGING ASSOCIATES, INC. 401(K) PROFIT SHARING PLAN 2009 401k financial data
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities2009-12-31$0

Form 5500 Responses for UTAH IMAGING ASSOCIATES, INC. 401(K) PROFIT SHARING PLAN

2022: UTAH IMAGING ASSOCIATES, INC. 401(K) PROFIT SHARING PLAN 2022 form 5500 responses
2022-01-01Type of plan entitySingle employer plan
2022-01-01Submission has been amendedNo
2022-01-01This submission is the final filingNo
2022-01-01This return/report is a short plan year return/report (less than 12 months)No
2022-01-01Plan is a collectively bargained planNo
2022-01-01Plan funding arrangement – InsuranceYes
2022-01-01Plan funding arrangement – TrustYes
2022-01-01Plan benefit arrangement – InsuranceYes
2022-01-01Plan benefit arrangement - TrustYes
2013: UTAH IMAGING ASSOCIATES, INC. 401(K) PROFIT SHARING PLAN 2013 form 5500 responses
2013-01-01Type of plan entitySingle employer plan
2013-01-01Submission has been amendedNo
2013-01-01This submission is the final filingNo
2013-01-01This return/report is a short plan year return/report (less than 12 months)No
2013-01-01Plan is a collectively bargained planNo
2013-01-01Plan funding arrangement – InsuranceYes
2013-01-01Plan funding arrangement – TrustYes
2013-01-01Plan benefit arrangement – InsuranceYes
2013-01-01Plan benefit arrangement - TrustYes
2012: UTAH IMAGING ASSOCIATES, INC. 401(K) PROFIT SHARING PLAN 2012 form 5500 responses
2012-01-01Type of plan entitySingle employer plan
2012-01-01Submission has been amendedYes
2012-01-01This submission is the final filingNo
2012-01-01This return/report is a short plan year return/report (less than 12 months)No
2012-01-01Plan is a collectively bargained planNo
2012-01-01Plan funding arrangement – InsuranceYes
2012-01-01Plan funding arrangement – TrustYes
2012-01-01Plan benefit arrangement – InsuranceYes
2012-01-01Plan benefit arrangement - TrustYes
2011: UTAH IMAGING ASSOCIATES, INC. 401(K) PROFIT SHARING PLAN 2011 form 5500 responses
2011-01-01Type of plan entitySingle employer plan
2011-01-01Submission has been amendedNo
2011-01-01This submission is the final filingNo
2011-01-01This return/report is a short plan year return/report (less than 12 months)No
2011-01-01Plan is a collectively bargained planNo
2011-01-01Plan funding arrangement – InsuranceYes
2011-01-01Plan funding arrangement – TrustYes
2011-01-01Plan benefit arrangement – InsuranceYes
2011-01-01Plan benefit arrangement - TrustYes
2009: UTAH IMAGING ASSOCIATES, INC. 401(K) PROFIT SHARING PLAN 2009 form 5500 responses
2009-01-01Type of plan entitySingle employer plan
2009-01-01Submission has been amendedYes
2009-01-01This submission is the final filingNo
2009-01-01This return/report is a short plan year return/report (less than 12 months)No
2009-01-01Plan is a collectively bargained planNo
2009-01-01Plan funding arrangement – InsuranceYes
2009-01-01Plan funding arrangement – TrustYes
2009-01-01Plan benefit arrangement – InsuranceYes
2009-01-01Plan benefit arrangement - TrustYes

Insurance Providers Used on plan

JOHN HANCOCK LIFE INSURANCE COMPANY (U.S.A.) (National Association of Insurance Commissioners NAIC id number: 65838 )
Policy contract number27059
Policy instance 1
Insurance contract or identification number27059
Number of Individuals Covered25
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $945
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 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
Amount paid for insurance broker fees945
Additional information about fees paid to insurance brokerTPA COMPENSATION
Insurance broker organization code?5
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract numberE0776219
Policy instance 3
Insurance contract or identification numberE0776219
Number of Individuals Covered1
Insurance policy start date2012-07-01
Insurance policy end date2013-06-30
Total amount of commissions paid to insurance brokerUSD $2,441
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 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
Commission paid to Insurance BrokerUSD $1,658
Insurance broker organization code?3
Insurance broker nameMORGAN STANLEY
SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 79065 )
Policy contract number1250172846
Policy instance 2
Insurance contract or identification number1250172846
Number of Individuals Covered1
Insurance policy start date2013-01-01
Insurance policy end date2013-12-31
Total amount of commissions paid to insurance brokerUSD $3,279
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 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
Commission paid to Insurance BrokerUSD $3,279
Insurance broker organization code?3
Insurance broker nameRBC CAPITAL MARKETS CORP
WESTERN RESERVE LIFE ASSURANCE-NORTHWIND, LLC (National Association of Insurance Commissioners NAIC id number: 85561 )
Policy contract number01P3565552
Policy instance 1
Insurance contract or identification number01P3565552
Number of Individuals Covered1
Insurance policy start date2013-01-01
Insurance policy end date2013-12-31
Total amount of commissions paid to insurance brokerUSD $8,000
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 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
Commission paid to Insurance BrokerUSD $8,000
Insurance broker organization code?3
Insurance broker nameW. CHARLES RICHARDS
AMERICAN NATIONAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60739 )
Policy contract number14533413
Policy instance 2
Insurance contract or identification number14533413
Number of Individuals Covered0
Insurance policy start date2012-01-01
Insurance policy end date2012-12-31
Total amount of commissions paid to insurance brokerUSD $0
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 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
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract numberE0776219
Policy instance 5
Insurance contract or identification numberE0776219
Number of Individuals Covered1
Insurance policy start date2011-07-01
Insurance policy end date2012-06-30
Total amount of commissions paid to insurance brokerUSD $0
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 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
SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 79065 )
Policy contract number1250172846
Policy instance 4
Insurance contract or identification number1250172846
Number of Individuals Covered1
Insurance policy start date2012-01-01
Insurance policy end date2012-12-31
Total amount of commissions paid to insurance brokerUSD $3,068
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 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
Commission paid to Insurance BrokerUSD $3,068
Insurance broker organization code?4
Insurance broker nameRBC CAPITAL MARKETS CORP
WESTERN RESERVE LIFE ASSURANCE-NORTHWIND, LLC (National Association of Insurance Commissioners NAIC id number: 85561 )
Policy contract number01P3565552
Policy instance 3
Insurance contract or identification number01P3565552
Number of Individuals Covered1
Insurance policy start date2012-01-01
Insurance policy end date2012-12-31
Total amount of commissions paid to insurance brokerUSD $0
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 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
JACKSON NATIONAL (National Association of Insurance Commissioners NAIC id number: 65056 )
Policy contract number31875940
Policy instance 1
Insurance contract or identification number31875940
Number of Individuals Covered0
Insurance policy start date2012-01-01
Insurance policy end date2012-12-31
Total amount of commissions paid to insurance brokerUSD $0
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 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
WESTERN RESERVE LIFE ASSURANCE-NORTHWIND, LLC (National Association of Insurance Commissioners NAIC id number: 85561 )
Policy contract number01P3565552
Policy instance 5
Insurance contract or identification number01P3565552
Insurance policy start date2011-01-01
Insurance policy end date2011-12-31
Total amount of commissions paid to insurance brokerUSD $0
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 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
SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 79065 )
Policy contract number1250172846
Policy instance 4
Insurance contract or identification number1250172846
Number of Individuals Covered1
Insurance policy start date2011-01-01
Insurance policy end date2011-12-31
Total amount of commissions paid to insurance brokerUSD $2,758
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 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
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract numberE0776219
Policy instance 3
Insurance contract or identification numberE0776219
Number of Individuals Covered1
Insurance policy start date2010-07-01
Insurance policy end date2011-06-30
Total amount of commissions paid to insurance brokerUSD $2,880
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 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
JACKSON NATIONAL (National Association of Insurance Commissioners NAIC id number: 65056 )
Policy contract number31875940
Policy instance 2
Insurance contract or identification number31875940
Number of Individuals Covered1
Insurance policy start date2011-01-01
Insurance policy end date2011-12-31
Total amount of commissions paid to insurance brokerUSD $0
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 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
AMERICAN NATIONAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60739 )
Policy contract number14533413
Policy instance 1
Insurance contract or identification number14533413
Number of Individuals Covered1
Insurance policy start date2011-01-01
Insurance policy end date2011-12-31
Total amount of commissions paid to insurance brokerUSD $0
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 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
WESTERN RESERVE LIFE ASSURANCE-NORTHWIND, LLC (National Association of Insurance Commissioners NAIC id number: 85561 )
Policy contract number01P3565552
Policy instance 7
Insurance contract or identification number01P3565552
Number of Individuals Covered1
Insurance policy start date2010-01-01
Insurance policy end date2010-12-31
Total amount of commissions paid to insurance brokerUSD $0
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 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
SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 79065 )
Policy contract number1250172846
Policy instance 6
Insurance contract or identification number1250172846
Number of Individuals Covered1
Insurance policy start date2010-01-01
Insurance policy end date2010-12-31
Total amount of commissions paid to insurance brokerUSD $275
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 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
Commission paid to Insurance BrokerUSD $275
Insurance broker organization code?4
Insurance broker nameRBC CAPITAL MARKETS CORP
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract numberE0776219
Policy instance 5
Insurance contract or identification numberE0776219
Number of Individuals Covered1
Insurance policy start date2009-07-01
Insurance policy end date2010-06-30
Total amount of commissions paid to insurance brokerUSD $8,000
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 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
Commission paid to Insurance BrokerUSD $8,000
Insurance broker organization code?3
Insurance broker nameTYLER LAMPRECHT
PACIFIC LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 67466 )
Policy contract numberVR01039205
Policy instance 4
Insurance contract or identification numberVR01039205
Number of Individuals Covered1
Insurance policy start date2010-01-01
Insurance policy end date2010-12-31
Total amount of commissions paid to insurance brokerUSD $0
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 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
AMERICAN NATIONAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60739 )
Policy contract number14533413
Policy instance 2
Insurance contract or identification number14533413
Number of Individuals Covered1
Insurance policy start date2010-01-01
Insurance policy end date2010-12-31
Total amount of commissions paid to insurance brokerUSD $0
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 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
ALLIANZ LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 90611 )
Policy contract number21342385
Policy instance 1
Insurance contract or identification number21342385
Number of Individuals Covered1
Insurance policy start date2010-01-01
Insurance policy end date2010-12-31
Total amount of commissions paid to insurance brokerUSD $0
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 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
JACKSON NATIONAL (National Association of Insurance Commissioners NAIC id number: 65056 )
Policy contract number31875940
Policy instance 3
Insurance contract or identification number31875940
Number of Individuals Covered1
Insurance policy start date2010-01-01
Insurance policy end date2010-12-31
Total amount of commissions paid to insurance brokerUSD $0
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 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

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