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SISKIYOU COMMUNITY HEALTH CENTER WELFARE BENEFITS PLAN 401k Plan overview

Plan NameSISKIYOU COMMUNITY HEALTH CENTER WELFARE BENEFITS PLAN
Plan identification number 501

SISKIYOU COMMUNITY HEALTH CENTER WELFARE BENEFITS PLAN Benefits

401k Plan TypeWelfare Benefit
Plan Features/Benefits
  • Health (other than dental or vision)
  • Life insurance
  • Dental
  • Vision
  • Temporary disability (accident and sickness)
  • Long-term disability cover
  • Other welfare benefit cover

401k Sponsoring company profile

SISKIYOU COMMUNITY HEALTH CENTER has sponsored the creation of one or more 401k plans.

Company Name:SISKIYOU COMMUNITY HEALTH CENTER
Employer identification number (EIN):930628804
NAIC Classification:621498
NAIC Description:All Other Outpatient Care Centers

Form 5500 Filing Information

Submission information for form 5500 for 401k plan SISKIYOU COMMUNITY HEALTH CENTER WELFARE BENEFITS PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5012022-01-01
5012021-01-01
5012020-01-01
5012019-01-01
5012018-01-01REBECCA ZACHA REBECCA ZACHA2019-05-30
5012017-01-01
5012016-01-01 REBECCA ZACHA2019-05-30
5012015-01-01 REBECCA ZACHA2019-05-30
5012014-01-01 REBECCA ZACHA2019-05-30
5012013-01-01 REBECCA ZACHA2019-05-30

Plan Statistics for SISKIYOU COMMUNITY HEALTH CENTER WELFARE BENEFITS PLAN

401k plan membership statisitcs for SISKIYOU COMMUNITY HEALTH CENTER WELFARE BENEFITS PLAN

Measure Date Value
2022: SISKIYOU COMMUNITY HEALTH CENTER WELFARE BENEFITS PLAN 2022 401k membership
Total participants, beginning-of-year2022-01-01190
Total number of active participants reported on line 7a of the Form 55002022-01-01190
Total of all active and inactive participants2022-01-01190
Total participants2022-01-01190
2021: SISKIYOU COMMUNITY HEALTH CENTER WELFARE BENEFITS PLAN 2021 401k membership
Total participants, beginning-of-year2021-01-01149
Total number of active participants reported on line 7a of the Form 55002021-01-01190
Number of retired or separated participants receiving benefits2021-01-010
Number of other retired or separated participants entitled to future benefits2021-01-010
Total of all active and inactive participants2021-01-01190
Total participants2021-01-01190
2020: SISKIYOU COMMUNITY HEALTH CENTER WELFARE BENEFITS PLAN 2020 401k membership
Total participants, beginning-of-year2020-01-01163
Total number of active participants reported on line 7a of the Form 55002020-01-01149
Number of retired or separated participants receiving benefits2020-01-010
Number of other retired or separated participants entitled to future benefits2020-01-010
Total of all active and inactive participants2020-01-01149
Total participants2020-01-01149
2019: SISKIYOU COMMUNITY HEALTH CENTER WELFARE BENEFITS PLAN 2019 401k membership
Total participants, beginning-of-year2019-01-01188
Total number of active participants reported on line 7a of the Form 55002019-01-01163
Number of retired or separated participants receiving benefits2019-01-010
Number of other retired or separated participants entitled to future benefits2019-01-010
Total of all active and inactive participants2019-01-01163
Total participants2019-01-01163
2018: SISKIYOU COMMUNITY HEALTH CENTER WELFARE BENEFITS PLAN 2018 401k membership
Total participants, beginning-of-year2018-01-01183
Total number of active participants reported on line 7a of the Form 55002018-01-01188
Total of all active and inactive participants2018-01-01188
Total participants2018-01-01188
2017: SISKIYOU COMMUNITY HEALTH CENTER WELFARE BENEFITS PLAN 2017 401k membership
Total participants, beginning-of-year2017-01-01168
Total number of active participants reported on line 7a of the Form 55002017-01-01183
Total of all active and inactive participants2017-01-01183
Total participants2017-01-01183
2016: SISKIYOU COMMUNITY HEALTH CENTER WELFARE BENEFITS PLAN 2016 401k membership
Total participants, beginning-of-year2016-01-01155
Total number of active participants reported on line 7a of the Form 55002016-01-01168
Total of all active and inactive participants2016-01-01168
Total participants2016-01-01168
2015: SISKIYOU COMMUNITY HEALTH CENTER WELFARE BENEFITS PLAN 2015 401k membership
Total participants, beginning-of-year2015-01-01129
Total number of active participants reported on line 7a of the Form 55002015-01-01155
Total of all active and inactive participants2015-01-01155
Total participants2015-01-01155
2014: SISKIYOU COMMUNITY HEALTH CENTER WELFARE BENEFITS PLAN 2014 401k membership
Total participants, beginning-of-year2014-01-01109
Total number of active participants reported on line 7a of the Form 55002014-01-01129
Total of all active and inactive participants2014-01-01129
Total participants2014-01-01129
2013: SISKIYOU COMMUNITY HEALTH CENTER WELFARE BENEFITS PLAN 2013 401k membership
Total participants, beginning-of-year2013-01-0197
Total number of active participants reported on line 7a of the Form 55002013-01-01109
Total of all active and inactive participants2013-01-01109
Total participants2013-01-01109

Form 5500 Responses for SISKIYOU COMMUNITY HEALTH CENTER WELFARE BENEFITS PLAN

2022: SISKIYOU COMMUNITY HEALTH CENTER WELFARE BENEFITS PLAN 2022 form 5500 responses
2022-01-01Type of plan entitySingle employer plan
2022-01-01Submission has been amendedNo
2022-01-01This submission is the final filingNo
2022-01-01This return/report is a short plan year return/report (less than 12 months)No
2022-01-01Plan is a collectively bargained planNo
2022-01-01Plan funding arrangement – InsuranceYes
2022-01-01Plan funding arrangement – General assets of the sponsorYes
2022-01-01Plan benefit arrangement – InsuranceYes
2022-01-01Plan benefit arrangement – General assets of the sponsorYes
2021: SISKIYOU COMMUNITY HEALTH CENTER WELFARE BENEFITS PLAN 2021 form 5500 responses
2021-01-01Type of plan entitySingle employer plan
2021-01-01Submission has been amendedNo
2021-01-01This submission is the final filingNo
2021-01-01This return/report is a short plan year return/report (less than 12 months)No
2021-01-01Plan is a collectively bargained planNo
2021-01-01Plan funding arrangement – InsuranceYes
2021-01-01Plan funding arrangement – General assets of the sponsorYes
2021-01-01Plan benefit arrangement – InsuranceYes
2021-01-01Plan benefit arrangement – General assets of the sponsorYes
2020: SISKIYOU COMMUNITY HEALTH CENTER WELFARE BENEFITS PLAN 2020 form 5500 responses
2020-01-01Type of plan entitySingle employer plan
2020-01-01Submission has been amendedNo
2020-01-01This submission is the final filingNo
2020-01-01This return/report is a short plan year return/report (less than 12 months)No
2020-01-01Plan is a collectively bargained planNo
2020-01-01Plan funding arrangement – InsuranceYes
2020-01-01Plan funding arrangement – General assets of the sponsorYes
2020-01-01Plan benefit arrangement – InsuranceYes
2020-01-01Plan benefit arrangement – General assets of the sponsorYes
2019: SISKIYOU COMMUNITY HEALTH CENTER WELFARE BENEFITS PLAN 2019 form 5500 responses
2019-01-01Type of plan entitySingle employer plan
2019-01-01Submission has been amendedNo
2019-01-01This submission is the final filingNo
2019-01-01This return/report is a short plan year return/report (less than 12 months)No
2019-01-01Plan is a collectively bargained planNo
2019-01-01Plan funding arrangement – InsuranceYes
2019-01-01Plan funding arrangement – General assets of the sponsorYes
2019-01-01Plan benefit arrangement – InsuranceYes
2019-01-01Plan benefit arrangement – General assets of the sponsorYes
2018: SISKIYOU COMMUNITY HEALTH CENTER WELFARE BENEFITS PLAN 2018 form 5500 responses
2018-01-01Type of plan entitySingle employer plan
2018-01-01Submission has been amendedNo
2018-01-01This submission is the final filingNo
2018-01-01This return/report is a short plan year return/report (less than 12 months)No
2018-01-01Plan is a collectively bargained planNo
2018-01-01Plan funding arrangement – InsuranceYes
2018-01-01Plan benefit arrangement – InsuranceYes
2017: SISKIYOU COMMUNITY HEALTH CENTER WELFARE BENEFITS PLAN 2017 form 5500 responses
2017-01-01Type of plan entitySingle employer plan
2017-01-01First time form 5500 has been submittedYes
2017-01-01Submission has been amendedNo
2017-01-01This submission is the final filingNo
2017-01-01This return/report is a short plan year return/report (less than 12 months)No
2017-01-01Plan is a collectively bargained planNo
2017-01-01Plan funding arrangement – InsuranceYes
2017-01-01Plan benefit arrangement – InsuranceYes
2016: SISKIYOU COMMUNITY HEALTH CENTER WELFARE BENEFITS PLAN 2016 form 5500 responses
2016-01-01Type of plan entitySingle employer plan
2016-01-01First time form 5500 has been submittedYes
2016-01-01Submission has been amendedNo
2016-01-01This submission is the final filingNo
2016-01-01This return/report is a short plan year return/report (less than 12 months)No
2016-01-01Plan is a collectively bargained planNo
2016-01-01Plan funding arrangement – InsuranceYes
2016-01-01Plan benefit arrangement – InsuranceYes
2015: SISKIYOU COMMUNITY HEALTH CENTER WELFARE BENEFITS PLAN 2015 form 5500 responses
2015-01-01Type of plan entitySingle employer plan
2015-01-01First time form 5500 has been submittedYes
2015-01-01Submission has been amendedNo
2015-01-01This submission is the final filingNo
2015-01-01This return/report is a short plan year return/report (less than 12 months)No
2015-01-01Plan is a collectively bargained planNo
2015-01-01Plan funding arrangement – InsuranceYes
2015-01-01Plan benefit arrangement – InsuranceYes
2014: SISKIYOU COMMUNITY HEALTH CENTER WELFARE BENEFITS PLAN 2014 form 5500 responses
2014-01-01Type of plan entitySingle employer plan
2014-01-01First time form 5500 has been submittedYes
2014-01-01Submission has been amendedNo
2014-01-01This submission is the final filingNo
2014-01-01This return/report is a short plan year return/report (less than 12 months)No
2014-01-01Plan is a collectively bargained planNo
2014-01-01Plan funding arrangement – InsuranceYes
2014-01-01Plan benefit arrangement – InsuranceYes
2013: SISKIYOU COMMUNITY HEALTH CENTER WELFARE BENEFITS PLAN 2013 form 5500 responses
2013-01-01Type of plan entitySingle employer plan
2013-01-01First time form 5500 has been submittedYes
2013-01-01Submission has been amendedNo
2013-01-01This submission is the final filingNo
2013-01-01This return/report is a short plan year return/report (less than 12 months)No
2013-01-01Plan is a collectively bargained planNo
2013-01-01Plan funding arrangement – InsuranceYes
2013-01-01Plan benefit arrangement – InsuranceYes

Insurance Providers Used on plan

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberG000B9JP
Policy instance 3
Insurance contract or identification numberG000B9JP
Number of Individuals Covered190
Insurance policy start date2022-01-01
Insurance policy end date2023-01-01
Total amount of commissions paid to insurance brokerUSD $27,105
Total amount of fees paid to insurance companyUSD $8,179
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&D, VOL LIFE & AD&D, VOL STD, CRITICAL ILLNESS, ACCIDENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $268,478
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $27,105
Amount paid for insurance broker fees8179
Insurance broker organization code?3
MODA HEALTH (National Association of Insurance Commissioners NAIC id number: 47098 )
Policy contract number10014868
Policy instance 2
Insurance contract or identification number10014868
Number of Individuals Covered240
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $59,350
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $1,977,495
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $59,350
Insurance broker organization code?3
UNITED HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 63983 )
Policy contract numberGV-4358
Policy instance 1
Insurance contract or identification numberGV-4358
Number of Individuals Covered142
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $2,318
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $23,178
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,318
Insurance broker organization code?3
MODA HEALTH (National Association of Insurance Commissioners NAIC id number: 47098 )
Policy contract number10014868
Policy instance 1
Insurance contract or identification number10014868
Number of Individuals Covered249
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $55,393
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $1,838,769
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $55,393
Insurance broker organization code?3
UNITED HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 63983 )
Policy contract numberGV-4358
Policy instance 2
Insurance contract or identification numberGV-4358
Number of Individuals Covered111
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $2,102
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $21,021
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Amount paid for insurance broker fees2102
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLTD0B9JP
Policy instance 3
Insurance contract or identification numberGLTD0B9JP
Number of Individuals Covered190
Insurance policy start date2021-01-01
Insurance policy end date2022-01-01
Total amount of commissions paid to insurance brokerUSD $7,598
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $50,654
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $7,598
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLUG0B9JP
Policy instance 4
Insurance contract or identification numberGLUG0B9JP
Number of Individuals Covered190
Insurance policy start date2021-01-01
Insurance policy end date2022-01-01
Total amount of commissions paid to insurance brokerUSD $1,040
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&D
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $10,402
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,040
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGUC0B9JP
Policy instance 5
Insurance contract or identification numberGUC0B9JP
Number of Individuals Covered57
Insurance policy start date2021-01-01
Insurance policy end date2022-01-01
Total amount of commissions paid to insurance brokerUSD $3,505
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $35,051
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,505
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGUDB0B9JP
Policy instance 6
Insurance contract or identification numberGUDB0B9JP
Number of Individuals Covered118
Insurance policy start date2021-01-01
Insurance policy end date2022-01-01
Total amount of commissions paid to insurance brokerUSD $4,424
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $88,488
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,424
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGUDE0B9JP
Policy instance 7
Insurance contract or identification numberGUDE0B9JP
Number of Individuals Covered25
Insurance policy start date2021-01-01
Insurance policy end date2022-01-01
Total amount of commissions paid to insurance brokerUSD $688
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedCRITICAL ILLNESS
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $6,878
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $688
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGUDH0B9JP
Policy instance 8
Insurance contract or identification numberGUDH0B9JP
Number of Individuals Covered67
Insurance policy start date2021-01-01
Insurance policy end date2022-01-01
Total amount of commissions paid to insurance brokerUSD $1,545
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $15,450
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,545
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGVTL0B9JP
Policy instance 9
Insurance contract or identification numberGVTL0B9JP
Number of Individuals Covered75
Insurance policy start date2021-01-01
Insurance policy end date2022-01-01
Total amount of commissions paid to insurance brokerUSD $3,819
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedVOLUNTARY LIFE
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $19,094
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,819
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGUDB0B9JP
Policy instance 5
Insurance contract or identification numberGUDB0B9JP
Number of Individuals Covered102
Insurance policy start date2020-01-01
Insurance policy end date2021-01-01
Total amount of commissions paid to insurance brokerUSD $4,396
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $87,923
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,396
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLUG0B9JP
Policy instance 4
Insurance contract or identification numberGLUG0B9JP
Number of Individuals Covered165
Insurance policy start date2020-01-01
Insurance policy end date2021-01-01
Total amount of commissions paid to insurance brokerUSD $987
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&D
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $9,875
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $987
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLTD0B9JP
Policy instance 3
Insurance contract or identification numberGLTD0B9JP
Number of Individuals Covered165
Insurance policy start date2020-01-01
Insurance policy end date2021-01-01
Total amount of commissions paid to insurance brokerUSD $7,087
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $47,248
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $7,087
Insurance broker organization code?3
UNITED HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 63983 )
Policy contract number4358
Policy instance 2
Insurance contract or identification number4358
Number of Individuals Covered111
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $1,964
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $19,639
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,964
Insurance broker organization code?3
MODA HEALTH (National Association of Insurance Commissioners NAIC id number: 47098 )
Policy contract number10014868
Policy instance 1
Insurance contract or identification number10014868
Number of Individuals Covered221
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $58,030
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $1,794,388
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $58,030
Insurance broker organization code?3
MODA HEALTH (National Association of Insurance Commissioners NAIC id number: 47098 )
Policy contract number10014868
Policy instance 1
Insurance contract or identification number10014868
Number of Individuals Covered241
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $50,768
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $1,692,273
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $8,751
Insurance broker organization code?3
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number30023538
Policy instance 2
Insurance contract or identification number30023538
Number of Individuals Covered116
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $1,222
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $23,870
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $194
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberG000B9JP
Policy instance 3
Insurance contract or identification numberG000B9JP
Number of Individuals Covered180
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $8,501
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $49,438
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,860
Insurance broker organization code?3
Amount paid for insurance broker fees1085
Additional information about fees paid to insurance brokerOTHER COMPENSATION
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLUG0B9JP
Policy instance 4
Insurance contract or identification numberGLUG0B9JP
Number of Individuals Covered181
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $1,332
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&D
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $10,943
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $273
Insurance broker organization code?3
Amount paid for insurance broker fees238
Additional information about fees paid to insurance brokerOTHER COMPENSATION
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGUDB0B9JP
Policy instance 5
Insurance contract or identification numberGUDB0B9JP
Number of Individuals Covered109
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $5,273
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $55,655
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,133
Insurance broker organization code?3
Amount paid for insurance broker fees818
Additional information about fees paid to insurance brokerOTHER COMPENSATION
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number30023538
Policy instance 4
Insurance contract or identification number30023538
Number of Individuals Covered122
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $1,251
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $24,832
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,251
Amount paid for insurance broker fees0
Insurance broker organization code?3
MODA HEALTH (National Association of Insurance Commissioners NAIC id number: 47098 )
Policy contract number10014868
Policy instance 3
Insurance contract or identification number10014868
Number of Individuals Covered162
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $44,361
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $1,478,693
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $44,361
Amount paid for insurance broker fees0
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberG000B9JP
Policy instance 2
Insurance contract or identification numberG000B9JP
Number of Individuals Covered184
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $108
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $10,872
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,087
Amount paid for insurance broker fees0
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberG000B9JP
Policy instance 1
Insurance contract or identification numberG000B9JP
Number of Individuals Covered184
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $7,403
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $49,354
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $7,403
Amount paid for insurance broker fees0
Insurance broker organization code?3
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number30023538
Policy instance 1
Insurance contract or identification number30023538
Number of Individuals Covered117
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $1,183
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $22,581
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
MODA HEALTH (National Association of Insurance Commissioners NAIC id number: 47098 )
Policy contract number10014868
Policy instance 2
Insurance contract or identification number10014868
Number of Individuals Covered155
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $40,501
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $1,350,022
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )
Policy contract number142712
Policy instance 3
Insurance contract or identification number142712
Number of Individuals Covered182
Insurance policy start date2017-07-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $1,169
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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
STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )
Policy contract number142712
Policy instance 4
Insurance contract or identification number142712
Number of Individuals Covered182
Insurance policy start date2017-07-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $3,588
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No

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