THE EVERGREEN SCHOOL has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan THE EVERGREEN SCHOOL WELFARE BENEFIT PLAN
Measure | Date | Value |
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2022: THE EVERGREEN SCHOOL WELFARE BENEFIT PLAN 2022 401k membership |
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Total participants, beginning-of-year | 2022-10-01 | 118 |
Total number of active participants reported on line 7a of the Form 5500 | 2022-10-01 | 108 |
Number of retired or separated participants receiving benefits | 2022-10-01 | 0 |
Number of other retired or separated participants entitled to future benefits | 2022-10-01 | 0 |
Total of all active and inactive participants | 2022-10-01 | 108 |
Number of employers contributing to the scheme | 2022-10-01 | 0 |
2021: THE EVERGREEN SCHOOL WELFARE BENEFIT PLAN 2021 401k membership |
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Total participants, beginning-of-year | 2021-10-01 | 114 |
Total number of active participants reported on line 7a of the Form 5500 | 2021-10-01 | 117 |
Number of retired or separated participants receiving benefits | 2021-10-01 | 0 |
Number of other retired or separated participants entitled to future benefits | 2021-10-01 | 0 |
Total of all active and inactive participants | 2021-10-01 | 117 |
Number of employers contributing to the scheme | 2021-10-01 | 0 |
2020: THE EVERGREEN SCHOOL WELFARE BENEFIT PLAN 2020 401k membership |
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Total participants, beginning-of-year | 2020-10-01 | 105 |
Total number of active participants reported on line 7a of the Form 5500 | 2020-10-01 | 110 |
Number of retired or separated participants receiving benefits | 2020-10-01 | 11 |
Number of other retired or separated participants entitled to future benefits | 2020-10-01 | 14 |
Total of all active and inactive participants | 2020-10-01 | 135 |
Number of employers contributing to the scheme | 2020-10-01 | 0 |
2019: THE EVERGREEN SCHOOL WELFARE BENEFIT PLAN 2019 401k membership |
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Total participants, beginning-of-year | 2019-10-01 | 110 |
Total number of active participants reported on line 7a of the Form 5500 | 2019-10-01 | 110 |
Number of retired or separated participants receiving benefits | 2019-10-01 | 0 |
Number of other retired or separated participants entitled to future benefits | 2019-10-01 | 0 |
Total of all active and inactive participants | 2019-10-01 | 110 |
2018: THE EVERGREEN SCHOOL WELFARE BENEFIT PLAN 2018 401k membership |
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Total participants, beginning-of-year | 2018-10-01 | 108 |
Total number of active participants reported on line 7a of the Form 5500 | 2018-10-01 | 109 |
Number of retired or separated participants receiving benefits | 2018-10-01 | 1 |
Number of other retired or separated participants entitled to future benefits | 2018-10-01 | 0 |
Total of all active and inactive participants | 2018-10-01 | 110 |
2017: THE EVERGREEN SCHOOL WELFARE BENEFIT PLAN 2017 401k membership |
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Total participants, beginning-of-year | 2017-10-01 | 106 |
Total number of active participants reported on line 7a of the Form 5500 | 2017-10-01 | 107 |
Number of retired or separated participants receiving benefits | 2017-10-01 | 1 |
Number of other retired or separated participants entitled to future benefits | 2017-10-01 | 0 |
Total of all active and inactive participants | 2017-10-01 | 108 |
2016: THE EVERGREEN SCHOOL WELFARE BENEFIT PLAN 2016 401k membership |
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Total participants, beginning-of-year | 2016-10-01 | 107 |
Total number of active participants reported on line 7a of the Form 5500 | 2016-10-01 | 106 |
Number of retired or separated participants receiving benefits | 2016-10-01 | 0 |
Number of other retired or separated participants entitled to future benefits | 2016-10-01 | 0 |
Total of all active and inactive participants | 2016-10-01 | 106 |
2015: THE EVERGREEN SCHOOL WELFARE BENEFIT PLAN 2015 401k membership |
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Total participants, beginning-of-year | 2015-10-01 | 103 |
Total number of active participants reported on line 7a of the Form 5500 | 2015-10-01 | 108 |
Number of retired or separated participants receiving benefits | 2015-10-01 | 1 |
Number of other retired or separated participants entitled to future benefits | 2015-10-01 | 0 |
Total of all active and inactive participants | 2015-10-01 | 109 |
2022: THE EVERGREEN SCHOOL WELFARE BENEFIT PLAN 2022 form 5500 responses |
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2022-10-01 | Type of plan entity | Single employer plan |
2022-10-01 | This return/report is a short plan year return/report (less than 12 months) | Yes |
2022-10-01 | Plan funding arrangement – Insurance | Yes |
2022-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2022-10-01 | Plan benefit arrangement – Insurance | Yes |
2022-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
2021: THE EVERGREEN SCHOOL WELFARE BENEFIT PLAN 2021 form 5500 responses |
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2021-10-01 | Type of plan entity | Single employer plan |
2021-10-01 | Plan funding arrangement – Insurance | Yes |
2021-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2021-10-01 | Plan benefit arrangement – Insurance | Yes |
2021-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
2020: THE EVERGREEN SCHOOL WELFARE BENEFIT PLAN 2020 form 5500 responses |
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2020-10-01 | Type of plan entity | Single employer plan |
2020-10-01 | Plan funding arrangement – Insurance | Yes |
2020-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2020-10-01 | Plan benefit arrangement – Insurance | Yes |
2020-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
2019: THE EVERGREEN SCHOOL WELFARE BENEFIT PLAN 2019 form 5500 responses |
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2019-10-01 | Type of plan entity | Single employer plan |
2019-10-01 | Submission has been amended | No |
2019-10-01 | This submission is the final filing | No |
2019-10-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2019-10-01 | Plan is a collectively bargained plan | No |
2019-10-01 | Plan funding arrangement – Insurance | Yes |
2019-10-01 | Plan benefit arrangement – Insurance | Yes |
2018: THE EVERGREEN SCHOOL WELFARE BENEFIT PLAN 2018 form 5500 responses |
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2018-10-01 | Type of plan entity | Single employer plan |
2018-10-01 | Submission has been amended | No |
2018-10-01 | This submission is the final filing | No |
2018-10-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2018-10-01 | Plan is a collectively bargained plan | No |
2018-10-01 | Plan funding arrangement – Insurance | Yes |
2018-10-01 | Plan benefit arrangement – Insurance | Yes |
2017: THE EVERGREEN SCHOOL WELFARE BENEFIT PLAN 2017 form 5500 responses |
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2017-10-01 | Type of plan entity | Single employer plan |
2017-10-01 | Submission has been amended | No |
2017-10-01 | This submission is the final filing | No |
2017-10-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2017-10-01 | Plan is a collectively bargained plan | No |
2017-10-01 | Plan funding arrangement – Insurance | Yes |
2017-10-01 | Plan benefit arrangement – Insurance | Yes |
2016: THE EVERGREEN SCHOOL WELFARE BENEFIT PLAN 2016 form 5500 responses |
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2016-10-01 | Type of plan entity | Single employer plan |
2016-10-01 | Submission has been amended | No |
2016-10-01 | This submission is the final filing | No |
2016-10-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2016-10-01 | Plan is a collectively bargained plan | No |
2016-10-01 | Plan funding arrangement – Insurance | Yes |
2016-10-01 | Plan benefit arrangement – Insurance | Yes |
2015: THE EVERGREEN SCHOOL WELFARE BENEFIT PLAN 2015 form 5500 responses |
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2015-10-01 | Type of plan entity | Single employer plan |
2015-10-01 | First time form 5500 has been submitted | Yes |
2015-10-01 | Submission has been amended | No |
2015-10-01 | This submission is the final filing | No |
2015-10-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2015-10-01 | Plan is a collectively bargained plan | No |
2015-10-01 | Plan funding arrangement – Insurance | Yes |
2015-10-01 | Plan benefit arrangement – Insurance | Yes |
GROUP HEALTH COOPERATIVE (National Association of Insurance Commissioners NAIC id number: 95672 ) |
Policy contract number | 2363400 |
Policy instance | 1 |
Insurance contract or identification number | 2363400 | Number of Individuals Covered | 3 | Insurance policy start date | 2022-02-01 | Insurance policy end date | 2022-12-31 | Total amount of commissions paid to insurance broker | USD $423 | Total amount of fees paid to insurance company | USD $0 | Health Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $7,042 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $423 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
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METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
Policy contract number | KM05391600 |
Policy instance | 2 |
Insurance contract or identification number | KM05391600 | Number of Individuals Covered | 196 | Insurance policy start date | 2022-10-01 | Insurance policy end date | 2022-12-31 | Total amount of commissions paid to insurance broker | USD $1,014 | Total amount of fees paid to insurance company | USD $59 | Dental Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $22,054 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $1,014 | Amount paid for insurance broker fees | 59 | Additional information about fees paid to insurance broker | NON-MONETARY COMPENSATION | Insurance broker organization code? | 3 |
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VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 53031 ) |
Policy contract number | 30004281 |
Policy instance | 3 |
Insurance contract or identification number | 30004281 | Number of Individuals Covered | 66 | Insurance policy start date | 2022-10-01 | Insurance policy end date | 2022-12-31 | Total amount of commissions paid to insurance broker | USD $222 | Total amount of fees paid to insurance company | USD $0 | Vision Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $2,186 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $222 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
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MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
Policy contract number | GLUG0B7NK |
Policy instance | 5 |
Insurance contract or identification number | GLUG0B7NK | Number of Individuals Covered | 116 | Insurance policy start date | 2022-10-01 | Insurance policy end date | 2022-12-31 | Total amount of commissions paid to insurance broker | USD $1,106 | Total amount of fees paid to insurance company | USD $0 | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | Yes | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT,EMPLOYEE ASSISTANCE PROGRAM | Welfare Benefit Premiums Paid to Carrier | USD $7,373 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $754 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
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GROUP HEALTH OPTIONS, INC. (National Association of Insurance Commissioners NAIC id number: 47055 ) |
Policy contract number | 8995900 |
Policy instance | 4 |
Insurance contract or identification number | 8995900 | Number of Individuals Covered | 143 | Insurance policy start date | 2022-02-01 | Insurance policy end date | 2022-12-31 | Total amount of commissions paid to insurance broker | USD $46,109 | Total amount of fees paid to insurance company | USD $0 | Health Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $862,404 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $46,109 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
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MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
Policy contract number | GLTD0B7NK |
Policy instance | 4 |
Insurance contract or identification number | GLTD0B7NK | Number of Individuals Covered | 117 | Insurance policy start date | 2021-10-01 | Insurance policy end date | 2022-09-30 | Total amount of commissions paid to insurance broker | USD $3,742 | Total amount of fees paid to insurance company | USD $1,540 | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | Yes | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | EMPLOYEE ASSISTANCE PROGRAM,ACCIDENTAL DEATH AND DISMEMBERMENT | Welfare Benefit Premiums Paid to Carrier | USD $24,946 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $3,742 | Amount paid for insurance broker fees | 1540 | Additional information about fees paid to insurance broker | OTHER COMPENSATION | Insurance broker organization code? | 3 |
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PREMERA BLUE CROSS (National Association of Insurance Commissioners NAIC id number: 47570 ) |
Policy contract number | 4020482 |
Policy instance | 1 |
Insurance contract or identification number | 4020482 | Number of Individuals Covered | 124 | Insurance policy start date | 2021-10-01 | Insurance policy end date | 2022-01-31 | Total amount of commissions paid to insurance broker | USD $20,047 | Total amount of fees paid to insurance company | USD $0 | Health Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $400,939 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $20,047 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
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METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
Policy contract number | 5391600 |
Policy instance | 2 |
Insurance contract or identification number | 5391600 | Number of Individuals Covered | 185 | Insurance policy start date | 2021-10-01 | Insurance policy end date | 2022-09-30 | Total amount of commissions paid to insurance broker | USD $3,928 | Total amount of fees paid to insurance company | USD $906 | Dental Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $83,892 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $3,928 | Amount paid for insurance broker fees | 906 | Additional information about fees paid to insurance broker | SUPPLEMENTAL/NON-MONETARY COMPENSATION | Insurance broker organization code? | 3 |
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VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 53031 ) |
Policy contract number | 30004281 |
Policy instance | 3 |
Insurance contract or identification number | 30004281 | Number of Individuals Covered | 64 | Insurance policy start date | 2021-10-01 | Insurance policy end date | 2022-09-30 | Total amount of commissions paid to insurance broker | USD $696 | Total amount of fees paid to insurance company | USD $0 | Vision Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $8,656 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $696 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
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PREMERA BLUE CROSS (National Association of Insurance Commissioners NAIC id number: 47570 ) |
Policy contract number | 4020482 |
Policy instance | 1 |
Insurance contract or identification number | 4020482 | Number of Individuals Covered | 110 | Insurance policy start date | 2020-10-01 | Insurance policy end date | 2021-09-30 | Total amount of commissions paid to insurance broker | USD $50,360 | Total amount of fees paid to insurance company | USD $0 | Health Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $1,007,198 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $50,360 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
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DELTA DENTAL OF WASHINGTON (National Association of Insurance Commissioners NAIC id number: 47341 ) |
Policy contract number | 1613 |
Policy instance | 2 |
Insurance contract or identification number | 1613 | Number of Individuals Covered | 155 | Insurance policy start date | 2020-10-01 | Insurance policy end date | 2021-09-30 | Total amount of commissions paid to insurance broker | USD $5,336 | Total amount of fees paid to insurance company | USD $0 | Dental Insurance Welfare Benefit | Yes | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | Commission paid to Insurance Broker | USD $5,336 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
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VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 53031 ) |
Policy contract number | 30004281 |
Policy instance | 3 |
Insurance contract or identification number | 30004281 | Number of Individuals Covered | 66 | Insurance policy start date | 2020-10-01 | Insurance policy end date | 2021-09-30 | Total amount of commissions paid to insurance broker | USD $653 | Total amount of fees paid to insurance company | USD $-99,999 | Vision Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $8,491 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $466 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 | Additional information about fees paid to insurance broker | FEES |
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MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
Policy contract number | GLTD0B7NK |
Policy instance | 4 |
Insurance contract or identification number | GLTD0B7NK | Number of Individuals Covered | 113 | Insurance policy start date | 2020-10-01 | Insurance policy end date | 2021-09-30 | Total amount of commissions paid to insurance broker | USD $3,550 | Total amount of fees paid to insurance company | USD $1,489 | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | Yes | Long Term Disability Insurance Welfare Benefit | Yes | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | EMPLOYEE ASSISTANCE PROGRAM,ACCIDENTAL DEATH AND DISMEMBERMENT | Welfare Benefit Premiums Paid to Carrier | USD $23,697 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $3,550 | Amount paid for insurance broker fees | 1489 | Additional information about fees paid to insurance broker | OTHER COMPENSATION | Insurance broker organization code? | 3 |
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MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
Policy contract number | GLTD0B7NK |
Policy instance | 6 |
Insurance contract or identification number | GLTD0B7NK | Number of Individuals Covered | 110 | Insurance policy start date | 2019-10-01 | Insurance policy end date | 2020-09-30 | Total amount of commissions paid to insurance broker | USD $2,045 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | Yes | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | EMPLOYEE ASSISTANCE PROGRAM | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $13,634 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $2,045 | Insurance broker organization code? | 3 |
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MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
Policy contract number | GLUG0B7NK |
Policy instance | 5 |
Insurance contract or identification number | GLUG0B7NK | Number of Individuals Covered | 110 | Insurance policy start date | 2019-10-01 | Insurance policy end date | 2020-09-30 | Total amount of commissions paid to insurance broker | USD $1,344 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | AD&D | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $8,960 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $1,344 | Insurance broker organization code? | 3 |
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DELTA DENTAL OF WASHINGTON (National Association of Insurance Commissioners NAIC id number: 47341 ) |
Policy contract number | 1613 |
Policy instance | 4 |
Insurance contract or identification number | 1613 | Number of Individuals Covered | 146 | Insurance policy start date | 2019-10-01 | Insurance policy end date | 2020-09-30 | Total amount of commissions paid to insurance broker | USD $4,052 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | Yes | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $4,052 | Insurance broker organization code? | 3 |
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MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
Policy contract number | GUG 0B7NK |
Policy instance | 3 |
Insurance contract or identification number | GUG 0B7NK | Number of Individuals Covered | 110 | Insurance policy start date | 2019-10-01 | Insurance policy end date | 2020-09-30 | Total amount of commissions paid to insurance broker | USD $991 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | Yes | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $6,610 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $991 | Insurance broker organization code? | 3 |
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VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 53031 ) |
Policy contract number | 30004281 |
Policy instance | 2 |
Insurance contract or identification number | 30004281 | Number of Individuals Covered | 63 | Insurance policy start date | 2019-10-01 | Insurance policy end date | 2020-09-30 | Total amount of commissions paid to insurance broker | USD $721 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | 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 $9,356 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $721 | Insurance broker organization code? | 3 |
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REGENCE BLUESHIELD (National Association of Insurance Commissioners NAIC id number: 53902 ) |
Policy contract number | 10015824 |
Policy instance | 1 |
Insurance contract or identification number | 10015824 | Number of Individuals Covered | 147 | Insurance policy start date | 2019-10-01 | Insurance policy end date | 2020-09-30 | Total amount of commissions paid to insurance broker | USD $50,031 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | Yes | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | 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 $1,027,927 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $50,031 | Insurance broker organization code? | 3 |
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REGENCE BLUESHIELD (National Association of Insurance Commissioners NAIC id number: 53902 ) |
Policy contract number | 10015824 |
Policy instance | 1 |
Insurance contract or identification number | 10015824 | Number of Individuals Covered | 150 | Insurance policy start date | 2018-10-01 | Insurance policy end date | 2019-09-30 | Total amount of commissions paid to insurance broker | USD $40,479 | Total amount of fees paid to insurance company | USD $2,160 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | Yes | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | 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 $976,219 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $40,479 | Amount paid for insurance broker fees | 2160 | Additional information about fees paid to insurance broker | BONUS | Insurance broker organization code? | 3 |
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VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 53031 ) |
Policy contract number | 30004281 |
Policy instance | 2 |
Insurance contract or identification number | 30004281 | Number of Individuals Covered | 69 | Insurance policy start date | 2018-10-01 | Insurance policy end date | 2019-09-30 | Total amount of commissions paid to insurance broker | USD $740 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | 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 $9,809 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $740 | Insurance broker organization code? | 3 |
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MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
Policy contract number | GUG 0B7NK |
Policy instance | 3 |
Insurance contract or identification number | GUG 0B7NK | Number of Individuals Covered | 109 | Insurance policy start date | 2018-10-01 | Insurance policy end date | 2019-09-30 | Total amount of commissions paid to insurance broker | USD $1,437 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | Yes | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $9,580 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $1,437 | Insurance broker organization code? | 3 |
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MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
Policy contract number | GLUG0B7NK |
Policy instance | 5 |
Insurance contract or identification number | GLUG0B7NK | Number of Individuals Covered | 109 | Insurance policy start date | 2018-10-01 | Insurance policy end date | 2019-09-30 | Total amount of commissions paid to insurance broker | USD $1,237 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | AD&D | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $8,246 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $1,237 | Insurance broker organization code? | 3 |
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DELTA DENTAL OF WASHINGTON (National Association of Insurance Commissioners NAIC id number: 47341 ) |
Policy contract number | 1613 |
Policy instance | 4 |
Insurance contract or identification number | 1613 | Number of Individuals Covered | 146 | Insurance policy start date | 2018-10-01 | Insurance policy end date | 2019-09-30 | Total amount of commissions paid to insurance broker | USD $4,736 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | Yes | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $4,736 | Insurance broker organization code? | 3 |
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MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
Policy contract number | GLTD0B7NK |
Policy instance | 6 |
Insurance contract or identification number | GLTD0B7NK | Number of Individuals Covered | 109 | Insurance policy start date | 2018-10-01 | Insurance policy end date | 2019-09-30 | Total amount of commissions paid to insurance broker | USD $1,868 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | Yes | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | EMPLOYEE ASSISTANCE PROGRAM | 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 $12,453 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $1,868 | Insurance broker organization code? | 3 |
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REGENCE BLUESHIELD (National Association of Insurance Commissioners NAIC id number: 53902 ) |
Policy contract number | 10015824 |
Policy instance | 1 |
Insurance contract or identification number | 10015824 | Number of Individuals Covered | 151 | Insurance policy start date | 2017-10-01 | Insurance policy end date | 2018-09-30 | Total amount of commissions paid to insurance broker | USD $41,742 | Total amount of fees paid to insurance company | USD $2,160 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | Yes | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | 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 $929,369 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
Policy contract number | GLTD0B7NK |
Policy instance | 6 |
Insurance contract or identification number | GLTD0B7NK | Number of Individuals Covered | 97 | Insurance policy start date | 2017-10-01 | Insurance policy end date | 2018-09-30 | Total amount of commissions paid to insurance broker | USD $1,776 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | 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 $11,842 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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DELTA DENTAL OF WASHINGTON (National Association of Insurance Commissioners NAIC id number: 47341 ) |
Policy contract number | 1613 |
Policy instance | 4 |
Insurance contract or identification number | 1613 | Number of Individuals Covered | 153 | Insurance policy start date | 2017-10-01 | Insurance policy end date | 2018-09-30 | Total amount of commissions paid to insurance broker | USD $4,428 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | Yes | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
Policy contract number | GLUG0B7NK |
Policy instance | 5 |
Insurance contract or identification number | GLUG0B7NK | Number of Individuals Covered | 97 | Insurance policy start date | 2017-10-01 | Insurance policy end date | 2018-09-30 | Total amount of commissions paid to insurance broker | USD $1,178 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | AD&D | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $7,852 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
Policy contract number | GUG 0B7NK |
Policy instance | 3 |
Insurance contract or identification number | GUG 0B7NK | Number of Individuals Covered | 97 | Insurance policy start date | 2017-10-01 | Insurance policy end date | 2018-09-30 | Total amount of commissions paid to insurance broker | USD $1,366 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | Yes | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $9,110 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 53031 ) |
Policy contract number | 30004281 |
Policy instance | 2 |
Insurance contract or identification number | 30004281 | Number of Individuals Covered | 71 | Insurance policy start date | 2017-10-01 | Insurance policy end date | 2018-09-30 | Total amount of commissions paid to insurance broker | USD $749 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | 0 | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | 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 $10,082 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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DELTA DENTAL OF WASHINGTON (National Association of Insurance Commissioners NAIC id number: 47341 ) |
Policy contract number | 1613 |
Policy instance | 4 |
Insurance contract or identification number | 1613 | Number of Individuals Covered | 148 | Insurance policy start date | 2015-10-01 | Insurance policy end date | 2016-09-30 | Total amount of commissions paid to insurance broker | USD $4,105 | 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 $82,096 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $4,105 | Insurance broker organization code? | 3 | Insurance broker name | THE VITOLO COMPANY |
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SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
Policy contract number | 213268 |
Policy instance | 3 |
Insurance contract or identification number | 213268 | Number of Individuals Covered | 99 | Insurance policy start date | 2015-10-01 | Insurance policy end date | 2016-09-30 | Total amount of commissions paid to insurance broker | USD $4,201 | 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 | Other welfare benefits provided | AD&D | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $30,901 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $4,201 | Insurance broker organization code? | 3 | Insurance broker name | THE VITOLO COMPANY |
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VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 53031 ) |
Policy contract number | 30004281 |
Policy instance | 2 |
Insurance contract or identification number | 30004281 | Number of Individuals Covered | 68 | Insurance policy start date | 2015-10-01 | Insurance policy end date | 2016-09-30 | Total amount of commissions paid to insurance broker | USD $665 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | No | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | 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 $8,395 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $665 | Insurance broker organization code? | 3 | Insurance broker name | THE VITOLO COMPANY |
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REGENCE BLUESHIELD (National Association of Insurance Commissioners NAIC id number: 53902 ) |
Policy contract number | 10015824 |
Policy instance | 1 |
Insurance contract or identification number | 10015824 | Number of Individuals Covered | 137 | Insurance policy start date | 2015-10-01 | Insurance policy end date | 2016-09-30 | Total amount of commissions paid to insurance broker | USD $42,264 | Total amount of fees paid to insurance company | USD $0 | Are there contracts with allocated funds for individual policies? | No | Are there contracts with allocated funds for group deferred annuity? | No | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | Health Insurance Welfare Benefit | Yes | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $856,882 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $42,264 | Insurance broker organization code? | 3 | Insurance broker name | THE VITOLO COMPANY |
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