COMMERCE CRG UTAH, LLC has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan COMMERCE CRG UTAH, LLC HEALTH & WELFARE PLAN
| Measure | Date | Value |
|---|
| 2015: COMMERCE CRG UTAH, LLC HEALTH & WELFARE PLAN 2015 401k membership |
|---|
| Total participants, beginning-of-year | 2015-03-01 | 128 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-03-01 | 0 |
| Number of retired or separated participants receiving benefits | 2015-03-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2015-03-01 | 0 |
| Total of all active and inactive participants | 2015-03-01 | 0 |
| 2014: COMMERCE CRG UTAH, LLC HEALTH & WELFARE PLAN 2014 401k membership |
|---|
| Total participants, beginning-of-year | 2014-03-01 | 136 |
| Total number of active participants reported on line 7a of the Form 5500 | 2014-03-01 | 128 |
| Number of retired or separated participants receiving benefits | 2014-03-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2014-03-01 | 0 |
| Total of all active and inactive participants | 2014-03-01 | 128 |
| 2013: COMMERCE CRG UTAH, LLC HEALTH & WELFARE PLAN 2013 401k membership |
|---|
| Total participants, beginning-of-year | 2013-03-01 | 121 |
| Total number of active participants reported on line 7a of the Form 5500 | 2013-03-01 | 136 |
| Number of other retired or separated participants entitled to future benefits | 2013-03-01 | 0 |
| Total of all active and inactive participants | 2013-03-01 | 136 |
| 2012: COMMERCE CRG UTAH, LLC HEALTH & WELFARE PLAN 2012 401k membership |
|---|
| Total participants, beginning-of-year | 2012-03-01 | 103 |
| Total number of active participants reported on line 7a of the Form 5500 | 2012-03-01 | 121 |
| Total of all active and inactive participants | 2012-03-01 | 121 |
| 2015: COMMERCE CRG UTAH, LLC HEALTH & WELFARE PLAN 2015 form 5500 responses |
|---|
| 2015-03-01 | Type of plan entity | Single employer plan |
| 2015-03-01 | Submission has been amended | No |
| 2015-03-01 | This submission is the final filing | Yes |
| 2015-03-01 | This return/report is a short plan year return/report (less than 12 months) | Yes |
| 2015-03-01 | Plan is a collectively bargained plan | No |
| 2015-03-01 | Plan funding arrangement – Insurance | Yes |
| 2015-03-01 | Plan benefit arrangement – Insurance | Yes |
| 2014: COMMERCE CRG UTAH, LLC HEALTH & WELFARE PLAN 2014 form 5500 responses |
|---|
| 2014-03-01 | Type of plan entity | Single employer plan |
| 2014-03-01 | Submission has been amended | No |
| 2014-03-01 | This submission is the final filing | No |
| 2014-03-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2014-03-01 | Plan is a collectively bargained plan | No |
| 2014-03-01 | Plan funding arrangement – Insurance | Yes |
| 2014-03-01 | Plan benefit arrangement – Insurance | Yes |
| 2013: COMMERCE CRG UTAH, LLC HEALTH & WELFARE PLAN 2013 form 5500 responses |
|---|
| 2013-03-01 | Type of plan entity | Single employer plan |
| 2013-03-01 | Submission has been amended | No |
| 2013-03-01 | This submission is the final filing | No |
| 2013-03-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2013-03-01 | Plan is a collectively bargained plan | No |
| 2013-03-01 | Plan funding arrangement – Insurance | Yes |
| 2013-03-01 | Plan benefit arrangement – Insurance | Yes |
| 2012: COMMERCE CRG UTAH, LLC HEALTH & WELFARE PLAN 2012 form 5500 responses |
|---|
| 2012-03-01 | Type of plan entity | Single employer plan |
| 2012-03-01 | First time form 5500 has been submitted | Yes |
| 2012-03-01 | Submission has been amended | No |
| 2012-03-01 | This submission is the final filing | No |
| 2012-03-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2012-03-01 | Plan is a collectively bargained plan | No |
| 2012-03-01 | Plan funding arrangement – Insurance | Yes |
| 2012-03-01 | Plan benefit arrangement – Insurance | Yes |
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 30032044 |
| Policy instance | 4 |
| Insurance contract or identification number | 30032044 | | Number of Individuals Covered | 59 | | Insurance policy start date | 2015-03-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $671 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $8,414 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $671 | | Insurance broker organization code? | 3 | | Insurance broker name | DAVIS PACIFIC BENEFITS, LLC |
|
| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | 40000100014802 |
| Policy instance | 3 |
| Insurance contract or identification number | 40000100014802 | | Number of Individuals Covered | 109 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $6,576 | | Total amount of fees paid to insurance company | USD $487 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $49,259 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,576 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 487 | | Additional information about fees paid to insurance broker | BONUS | | Insurance broker name | FRINGE BENEFIT ANALYSTS, LLC |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 498516 |
| Policy instance | 2 |
| Insurance contract or identification number | 498516 | | Number of Individuals Covered | 108 | | Insurance policy start date | 2015-03-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $3,127 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $75,136 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,127 | | Insurance broker organization code? | 3 | | Insurance broker name | TODD G. STEINICKE |
|
| REGENCE BLUECROSS BLUESHIELD OF UTAH (National Association of Insurance Commissioners NAIC id number: 54550 ) |
| Policy contract number | 10011462 |
| Policy instance | 1 |
| Insurance contract or identification number | 10011462 | | Number of Individuals Covered | 209 | | Insurance policy start date | 2015-03-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $27,296 | | Total amount of fees paid to insurance company | USD $6,529 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $1,006,735 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $27,296 | | Amount paid for insurance broker fees | 6529 | | Additional information about fees paid to insurance broker | BONUS | | Insurance broker organization code? | 3 | | Insurance broker name | DAVIS PACIFIC BENEFITS, LLC |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 30032044 |
| Policy instance | 4 |
| Insurance contract or identification number | 30032044 | | Number of Individuals Covered | 79 | | Insurance policy start date | 2014-03-01 | | Insurance policy end date | 2015-02-28 | | Total amount of commissions paid to insurance broker | USD $837 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $12,445 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $837 | | Insurance broker organization code? | 3 | | Insurance broker name | DAVIS PACIFIC BENEFITS, LLC |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 498516 |
| Policy instance | 2 |
| Insurance contract or identification number | 498516 | | Number of Individuals Covered | 128 | | Insurance policy start date | 2014-03-01 | | Insurance policy end date | 2015-02-28 | | Total amount of commissions paid to insurance broker | USD $3,247 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $83,114 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,247 | | Insurance broker organization code? | 3 | | Insurance broker name | TODD G. STEINICKE |
|
| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | 40000100014802 |
| Policy instance | 3 |
| Insurance contract or identification number | 40000100014802 | | Number of Individuals Covered | 109 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $6,579 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $48,654 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,579 | | Insurance broker organization code? | 3 | | Insurance broker name | PACIFIC SERVICE INSURANCE, INC. |
|
| REGENCE BLUECROSS BLUESHIELD OF UTAH (National Association of Insurance Commissioners NAIC id number: 54550 ) |
| Policy contract number | 10011462 |
| Policy instance | 1 |
| Insurance contract or identification number | 10011462 | | Number of Individuals Covered | 224 | | Insurance policy start date | 2014-03-01 | | Insurance policy end date | 2015-02-28 | | Total amount of commissions paid to insurance broker | USD $38,707 | | Total amount of fees paid to insurance company | USD $11,612 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $1,288,547 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $38,707 | | Amount paid for insurance broker fees | 11612 | | Additional information about fees paid to insurance broker | BONUS | | Insurance broker organization code? | 3 | | Insurance broker name | DAVIS PACIFIC BENEFITS, LLC |
|
| REGENCE BLUECROSS BLUESHIELD OF UTAH (National Association of Insurance Commissioners NAIC id number: 54550 ) |
| Policy contract number | 10011462 |
| Policy instance | 6 |
| Insurance contract or identification number | 10011462 | | Number of Individuals Covered | 136 | | Insurance policy start date | 2013-03-01 | | Insurance policy end date | 2014-02-28 | | Total amount of commissions paid to insurance broker | USD $42,074 | | Total amount of fees paid to insurance company | USD $12,880 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,310,932 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $42,074 | | Amount paid for insurance broker fees | 12880 | | Additional information about fees paid to insurance broker | BROKER BONUS | | Insurance broker organization code? | 3 | | Insurance broker name | DAVIS PACIFIC BENEFITS |
|
| DENTIST DIRECT, LLC (National Association of Insurance Commissioners NAIC id number: 52429 ) |
| Policy contract number | ACX21 |
| Policy instance | 5 |
| Insurance contract or identification number | ACX21 | | Number of Individuals Covered | 137 | | Insurance policy start date | 2013-10-01 | | Insurance policy end date | 2014-02-28 | | Total amount of commissions paid to insurance broker | USD $7,954 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $132,574 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,954 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | DAVIS PACIFIC BENEFITS |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 30032044 |
| Policy instance | 4 |
| Insurance contract or identification number | 30032044 | | Number of Individuals Covered | 75 | | Insurance policy start date | 2013-03-01 | | Insurance policy end date | 2014-02-28 | | Total amount of commissions paid to insurance broker | USD $860 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $13,103 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $860 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | DAVIS PACIFIC BENEFITS, LLC |
|
| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | 10076109 |
| Policy instance | 3 |
| Insurance contract or identification number | 10076109 | | Number of Individuals Covered | 113 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $3,338 | | Total amount of fees paid to insurance company | USD $263 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $26,754 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,338 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Additional information about fees paid to insurance broker | BROKER BONUS | | Insurance broker name | FRINGE BENEFIT ANALYSTS LLC |
|
| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | 10156492 |
| Policy instance | 2 |
| Insurance contract or identification number | 10156492 | | Number of Individuals Covered | 26 | | Insurance policy start date | 2013-03-01 | | Insurance policy end date | 2014-02-28 | | Total amount of commissions paid to insurance broker | USD $1,223 | | Total amount of fees paid to insurance company | USD $249 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $8,156 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $0 | | Amount paid for insurance broker fees | 249 | | Additional information about fees paid to insurance broker | BROKER BONUS | | Insurance broker organization code? | 3 | | Insurance broker name | PACIFIC SERVICE INSURANCE INC |
|
| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | 100014802 |
| Policy instance | 1 |
| Insurance contract or identification number | 100014802 | | Number of Individuals Covered | 95 | | Insurance policy start date | 2013-03-01 | | Insurance policy end date | 2014-02-28 | | Total amount of commissions paid to insurance broker | USD $1,987 | | Total amount of fees paid to insurance company | USD $372 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $13,245 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $0 | | Amount paid for insurance broker fees | 372 | | Additional information about fees paid to insurance broker | BROKER BONUS | | Insurance broker organization code? | 3 | | Insurance broker name | PACIFIC SERVICE INSURANCE INC |
|
| REGENCE BLUECROSS BLUESHIELD OF UTAH (National Association of Insurance Commissioners NAIC id number: 54550 ) |
| Policy contract number | 10011462 |
| Policy instance | 4 |
| Insurance contract or identification number | 10011462 | | Number of Individuals Covered | 120 | | Insurance policy start date | 2012-03-01 | | Insurance policy end date | 2013-02-28 | | Total amount of commissions paid to insurance broker | USD $27,967 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,119,739 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $27,967 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | DAVIS PACIFIC BENEFITS |
|
| DENTIST DIRECT, LLC (National Association of Insurance Commissioners NAIC id number: 52429 ) |
| Policy contract number | ACX21 |
| Policy instance | 3 |
| Insurance contract or identification number | ACX21 | | Number of Individuals Covered | 121 | | Insurance policy start date | 2011-10-01 | | Insurance policy end date | 2012-09-30 | | Total amount of commissions paid to insurance broker | USD $5,244 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $87,568 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,244 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | DAVIS PACIFIC BENEFITS |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 30032044 |
| Policy instance | 2 |
| Insurance contract or identification number | 30032044 | | Number of Individuals Covered | 68 | | Insurance policy start date | 2012-03-01 | | Insurance policy end date | 2013-02-28 | | Total amount of commissions paid to insurance broker | USD $819 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $11,935 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $819 | | Insurance broker organization code? | 3 | | Insurance broker name | DAVIS PACIFIC BENEFITS, LLC |
|
| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | 10076109 |
| Policy instance | 1 |
| Insurance contract or identification number | 10076109 | | Number of Individuals Covered | 103 | | Insurance policy start date | 2012-03-01 | | Insurance policy end date | 2013-02-28 | | Total amount of commissions paid to insurance broker | USD $3,239 | | Total amount of fees paid to insurance company | USD $0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $25,801 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,239 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | PACIFIC SERVICE INSURANCE, INC. |
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