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SAMARITAN HEALTH SERVICES BENEFIT PLAN 401k Plan overview

Plan NameSAMARITAN HEALTH SERVICES BENEFIT PLAN
Plan identification number 505

SAMARITAN HEALTH SERVICES BENEFIT 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
  • Death benefits (include travel accident but not life insurance)
  • Other welfare benefit cover

401k Sponsoring company profile

SAMARITAN HEALTH SERVICES has sponsored the creation of one or more 401k plans.

Company Name:SAMARITAN HEALTH SERVICES
Employer identification number (EIN):930951989
NAIC Classification:622000
NAIC Description: Hospitals

Form 5500 Filing Information

Submission information for form 5500 for 401k plan SAMARITAN HEALTH SERVICES BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5052022-01-01DANIEL B SMITH2023-10-12 DANIEL B SMITH2023-10-12
5052021-01-01
5052020-01-01
5052019-01-01
5052018-01-01
5052017-01-01DANIEL B. SMITH DANIEL B. SMITH2018-10-10
5052016-01-01DANIEL B. SMITH DANIEL B. SMITH2017-10-06
5052015-01-01DANIEL B. SMITH DANIEL B. SMITH2016-10-07
5052014-01-01DANIEL B. SMITH DANIEL B. SMITH2015-07-30
5052013-01-01DANIEL B. SMITH DANIEL B. SMITH2014-07-23
5052012-01-01DANIEL B. SMITH DANIEL B. SMITH2013-07-25
5052011-01-01DANIEL B. SMITH DANIEL B. SMITH2012-10-11
5052010-01-01DANIEL B SMITH
5052009-01-01DANIEL B SMITH
5052009-01-01DANIEL B SMITH
5052009-01-01DANIEL B SMITH
5052009-01-01DANIEL B SMITH

Plan Statistics for SAMARITAN HEALTH SERVICES BENEFIT PLAN

401k plan membership statisitcs for SAMARITAN HEALTH SERVICES BENEFIT PLAN

Measure Date Value
2022: SAMARITAN HEALTH SERVICES BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year2022-01-015,489
Total number of active participants reported on line 7a of the Form 55002022-01-015,548
Number of retired or separated participants receiving benefits2022-01-0144
Number of other retired or separated participants entitled to future benefits2022-01-010
Total of all active and inactive participants2022-01-015,592
2021: SAMARITAN HEALTH SERVICES BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year2021-01-015,417
Total number of active participants reported on line 7a of the Form 55002021-01-015,360
Number of retired or separated participants receiving benefits2021-01-0173
Total of all active and inactive participants2021-01-015,433
Total participants2021-01-015,433
2020: SAMARITAN HEALTH SERVICES BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year2020-01-015,429
Total number of active participants reported on line 7a of the Form 55002020-01-015,317
Number of retired or separated participants receiving benefits2020-01-0178
Total of all active and inactive participants2020-01-015,395
Total participants2020-01-015,395
2019: SAMARITAN HEALTH SERVICES BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year2019-01-015,561
Total number of active participants reported on line 7a of the Form 55002019-01-015,298
Number of retired or separated participants receiving benefits2019-01-01131
Total of all active and inactive participants2019-01-015,429
2018: SAMARITAN HEALTH SERVICES BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year2018-01-015,571
Total number of active participants reported on line 7a of the Form 55002018-01-015,467
Number of retired or separated participants receiving benefits2018-01-0194
Total of all active and inactive participants2018-01-015,561
Total participants2018-01-015,561
2017: SAMARITAN HEALTH SERVICES BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year2017-01-015,464
Total number of active participants reported on line 7a of the Form 55002017-01-015,480
Number of retired or separated participants receiving benefits2017-01-0191
Total of all active and inactive participants2017-01-015,571
Total participants2017-01-015,571
2016: SAMARITAN HEALTH SERVICES BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year2016-01-015,035
Total number of active participants reported on line 7a of the Form 55002016-01-015,421
Number of retired or separated participants receiving benefits2016-01-0143
Total of all active and inactive participants2016-01-015,464
Total participants2016-01-015,464
2015: SAMARITAN HEALTH SERVICES BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year2015-01-014,751
Total number of active participants reported on line 7a of the Form 55002015-01-014,997
Number of retired or separated participants receiving benefits2015-01-0138
Total of all active and inactive participants2015-01-015,035
Total participants2015-01-015,035
2014: SAMARITAN HEALTH SERVICES BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year2014-01-014,553
Total number of active participants reported on line 7a of the Form 55002014-01-014,704
Number of retired or separated participants receiving benefits2014-01-0147
Total of all active and inactive participants2014-01-014,751
Total participants2014-01-014,751
2013: SAMARITAN HEALTH SERVICES BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year2013-01-014,569
Total number of active participants reported on line 7a of the Form 55002013-01-014,498
Number of retired or separated participants receiving benefits2013-01-0155
Total of all active and inactive participants2013-01-014,553
Total participants2013-01-014,553
2012: SAMARITAN HEALTH SERVICES BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year2012-01-014,654
Total number of active participants reported on line 7a of the Form 55002012-01-014,499
Number of retired or separated participants receiving benefits2012-01-0170
Total of all active and inactive participants2012-01-014,569
Total participants2012-01-014,569
2011: SAMARITAN HEALTH SERVICES BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year2011-01-014,730
Total number of active participants reported on line 7a of the Form 55002011-01-014,601
Number of retired or separated participants receiving benefits2011-01-0153
Total of all active and inactive participants2011-01-014,654
Total participants2011-01-014,654
2010: SAMARITAN HEALTH SERVICES BENEFIT PLAN 2010 401k membership
Total participants, beginning-of-year2010-01-014,599
Total number of active participants reported on line 7a of the Form 55002010-01-014,638
Number of retired or separated participants receiving benefits2010-01-0192
Total of all active and inactive participants2010-01-014,730
Total participants2010-01-014,730
2009: SAMARITAN HEALTH SERVICES BENEFIT PLAN 2009 401k membership
Total participants, beginning-of-year2009-01-014,336
Total number of active participants reported on line 7a of the Form 55002009-01-014,531
Number of retired or separated participants receiving benefits2009-01-0168
Total of all active and inactive participants2009-01-014,599
Total participants2009-01-014,599

Form 5500 Responses for SAMARITAN HEALTH SERVICES BENEFIT PLAN

2022: SAMARITAN HEALTH SERVICES BENEFIT 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 planYes
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: SAMARITAN HEALTH SERVICES BENEFIT PLAN 2021 form 5500 responses
2021-01-01Type of plan entitySingle employer plan
2021-01-01Plan is a collectively bargained planYes
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: SAMARITAN HEALTH SERVICES BENEFIT PLAN 2020 form 5500 responses
2020-01-01Type of plan entitySingle employer plan
2020-01-01Plan is a collectively bargained planYes
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: SAMARITAN HEALTH SERVICES BENEFIT PLAN 2019 form 5500 responses
2019-01-01Type of plan entitySingle employer plan
2019-01-01Plan is a collectively bargained planYes
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: SAMARITAN HEALTH SERVICES BENEFIT PLAN 2018 form 5500 responses
2018-01-01Type of plan entitySingle employer plan
2018-01-01Plan is a collectively bargained planYes
2018-01-01Plan funding arrangement – InsuranceYes
2018-01-01Plan funding arrangement – General assets of the sponsorYes
2018-01-01Plan benefit arrangement – InsuranceYes
2018-01-01Plan benefit arrangement – General assets of the sponsorYes
2017: SAMARITAN HEALTH SERVICES BENEFIT PLAN 2017 form 5500 responses
2017-01-01Type of plan entitySingle employer plan
2017-01-01Plan is a collectively bargained planYes
2017-01-01Plan funding arrangement – InsuranceYes
2017-01-01Plan funding arrangement – General assets of the sponsorYes
2017-01-01Plan benefit arrangement – InsuranceYes
2017-01-01Plan benefit arrangement – General assets of the sponsorYes
2016: SAMARITAN HEALTH SERVICES BENEFIT PLAN 2016 form 5500 responses
2016-01-01Type of plan entitySingle employer plan
2016-01-01Plan is a collectively bargained planYes
2016-01-01Plan funding arrangement – InsuranceYes
2016-01-01Plan funding arrangement – General assets of the sponsorYes
2016-01-01Plan benefit arrangement – InsuranceYes
2016-01-01Plan benefit arrangement – General assets of the sponsorYes
2015: SAMARITAN HEALTH SERVICES BENEFIT PLAN 2015 form 5500 responses
2015-01-01Type of plan entitySingle employer plan
2015-01-01Plan is a collectively bargained planYes
2015-01-01Plan funding arrangement – InsuranceYes
2015-01-01Plan funding arrangement – General assets of the sponsorYes
2015-01-01Plan benefit arrangement – InsuranceYes
2015-01-01Plan benefit arrangement – General assets of the sponsorYes
2014: SAMARITAN HEALTH SERVICES BENEFIT PLAN 2014 form 5500 responses
2014-01-01Type of plan entitySingle employer plan
2014-01-01Plan is a collectively bargained planYes
2014-01-01Plan funding arrangement – InsuranceYes
2014-01-01Plan funding arrangement – General assets of the sponsorYes
2014-01-01Plan benefit arrangement – InsuranceYes
2014-01-01Plan benefit arrangement – General assets of the sponsorYes
2013: SAMARITAN HEALTH SERVICES BENEFIT PLAN 2013 form 5500 responses
2013-01-01Type of plan entitySingle employer plan
2013-01-01Plan is a collectively bargained planYes
2013-01-01Plan funding arrangement – InsuranceYes
2013-01-01Plan funding arrangement – General assets of the sponsorYes
2013-01-01Plan benefit arrangement – InsuranceYes
2013-01-01Plan benefit arrangement – General assets of the sponsorYes
2012: SAMARITAN HEALTH SERVICES BENEFIT PLAN 2012 form 5500 responses
2012-01-01Type of plan entitySingle employer plan
2012-01-01Plan is a collectively bargained planYes
2012-01-01Plan funding arrangement – InsuranceYes
2012-01-01Plan funding arrangement – General assets of the sponsorYes
2012-01-01Plan benefit arrangement – InsuranceYes
2012-01-01Plan benefit arrangement – General assets of the sponsorYes
2011: SAMARITAN HEALTH SERVICES BENEFIT PLAN 2011 form 5500 responses
2011-01-01Type of plan entitySingle employer plan
2011-01-01Plan is a collectively bargained planYes
2011-01-01Plan funding arrangement – InsuranceYes
2011-01-01Plan funding arrangement – General assets of the sponsorYes
2011-01-01Plan benefit arrangement – InsuranceYes
2011-01-01Plan benefit arrangement – General assets of the sponsorYes
2010: SAMARITAN HEALTH SERVICES BENEFIT PLAN 2010 form 5500 responses
2010-01-01Type of plan entitySingle employer plan
2010-01-01Plan is a collectively bargained planYes
2010-01-01Plan funding arrangement – InsuranceYes
2010-01-01Plan funding arrangement – General assets of the sponsorYes
2010-01-01Plan benefit arrangement – InsuranceYes
2010-01-01Plan benefit arrangement – General assets of the sponsorYes
2009: SAMARITAN HEALTH SERVICES BENEFIT PLAN 2009 form 5500 responses
2009-01-01Type of plan entitySingle employer plan
2009-01-01Submission has been amendedYes
2009-01-01Plan is a collectively bargained planYes
2009-01-01Plan funding arrangement – InsuranceYes
2009-01-01Plan funding arrangement – General assets of the sponsorYes
2009-01-01Plan benefit arrangement – InsuranceYes
2009-01-01Plan benefit arrangement – General assets of the sponsorYes

Insurance Providers Used on plan

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberOK 969031
Policy instance 11
Insurance contract or identification numberOK 969031
Number of Individuals Covered6048
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $2,326
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 BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
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 $93,035
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,326
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberOK 969196
Policy instance 6
Insurance contract or identification numberOK 969196
Number of Individuals Covered1988
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $4,051
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 BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
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 $162,057
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,051
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberFLX967522
Policy instance 7
Insurance contract or identification numberFLX967522
Number of Individuals Covered6048
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $10,912
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 $436,466
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $10,912
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberLK 965146
Policy instance 8
Insurance contract or identification numberLK 965146
Number of Individuals Covered5398
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $48,398
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 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 $1,935,914
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $48,398
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberAI 960282
Policy instance 9
Insurance contract or identification numberAI 960282
Number of Individuals Covered1659
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $74,762
Total amount of fees paid to insurance companyUSD $7,156
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 providedACCIDENTAL INJURY
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 $401,690
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $74,762
Amount paid for insurance broker fees7156
Additional information about fees paid to insurance brokerOVERRIDES
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberVDT962204
Policy instance 10
Insurance contract or identification numberVDT962204
Number of Individuals Covered3229
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $48,259
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 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 $1,930,351
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $48,259
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberLK 752070
Policy instance 12
Insurance contract or identification numberLK 752070
Number of Individuals Covered491
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $12,160
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 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 $486,412
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $12,160
Insurance broker organization code?3
WILLAMETTE DENTAL INSURANCE, INC. (National Association of Insurance Commissioners NAIC id number: 57069 )
Policy contract numberOR134/OR135
Policy instance 13
Insurance contract or identification numberOR134/OR135
Number of Individuals Covered4507
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
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 $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberFLX967685
Policy instance 5
Insurance contract or identification numberFLX967685
Number of Individuals Covered3676
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $41,478
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 $1,659,128
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $41,478
Insurance broker organization code?3
PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )
Policy contract number0008461032
Policy instance 4
Insurance contract or identification number0008461032
Number of Individuals Covered340
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $6,318
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedCRITICAL 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 $130,529
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,418
Insurance broker organization code?3
ACE AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 22667 )
Policy contract numberADD N04224310
Policy instance 3
Insurance contract or identification numberADD N04224310
Number of Individuals Covered628
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $285
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 BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
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 $1,900
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $285
Insurance broker organization code?3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number091135
Policy instance 2
Insurance contract or identification number091135
Number of Individuals Covered442
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $9,089
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 BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedLONG TERM CARE
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 $60,596
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $9,089
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberCI 960295
Policy instance 1
Insurance contract or identification numberCI 960295
Number of Individuals Covered2156
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $85,994
Total amount of fees paid to insurance companyUSD $8,564
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 $462,094
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $85,994
Amount paid for insurance broker fees8564
Additional information about fees paid to insurance brokerOVERRIDES
Insurance broker organization code?3
OREGON DENTAL SERVICE (National Association of Insurance Commissioners NAIC id number: 54941 )
Policy contract number10000122
Policy instance 1
Insurance contract or identification number10000122
Number of Individuals Covered2802
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $3,734,480
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
WILLAMETTE DENTAL INSURANCE, INC. (National Association of Insurance Commissioners NAIC id number: 57069 )
Policy contract numberOR134/OR135
Policy instance 2
Insurance contract or identification numberOR134/OR135
Number of Individuals Covered2163
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberCI 960295
Policy instance 3
Insurance contract or identification numberCI 960295
Number of Individuals Covered1897
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $93,395
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedCRITICAL ILLNESS
Welfare Benefit Premiums Paid to CarrierUSD $431,499
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $93,395
Insurance broker organization code?3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number091135
Policy instance 4
Insurance contract or identification number091135
Number of Individuals Covered471
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $23,214
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedLONG TERM CARE
Welfare Benefit Premiums Paid to CarrierUSD $154,583
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $23,214
Insurance broker organization code?3
ACE AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 22667 )
Policy contract numberADD N04224310
Policy instance 5
Insurance contract or identification numberADD N04224310
Number of Individuals Covered628
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $285
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedACCIDENTAL DEATH
Welfare Benefit Premiums Paid to CarrierUSD $1,900
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $285
Insurance broker organization code?3
PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )
Policy contract number0008461032
Policy instance 6
Insurance contract or identification number0008461032
Number of Individuals Covered386
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $6,378
Total amount of fees paid to insurance companyUSD $0
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $130,760
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,247
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberFLX967685
Policy instance 7
Insurance contract or identification numberFLX967685
Number of Individuals Covered3800
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $5,814
Total amount of fees paid to insurance companyUSD $20,021
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $236,278
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,814
Amount paid for insurance broker fees20021
Additional information about fees paid to insurance brokerBONUS
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberOK 969196
Policy instance 8
Insurance contract or identification numberOK 969196
Number of Individuals Covered1913
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $2,991
Total amount of fees paid to insurance companyUSD $3,071
Other welfare benefits providedACCIDENTAL DEATH
Welfare Benefit Premiums Paid to CarrierUSD $119,651
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,991
Amount paid for insurance broker fees3071
Additional information about fees paid to insurance brokerBONUS
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberLK 752070
Policy instance 14
Insurance contract or identification numberLK 752070
Number of Individuals Covered480
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $1,619
Total amount of fees paid to insurance companyUSD $7,770
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $64,775
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,619
Amount paid for insurance broker fees7770
Additional information about fees paid to insurance brokerBONUS
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberOK 969031
Policy instance 13
Insurance contract or identification numberOK 969031
Number of Individuals Covered5293
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $2,271
Total amount of fees paid to insurance companyUSD $1,801
Other welfare benefits providedACCIDENTAL DEATH
Welfare Benefit Premiums Paid to CarrierUSD $90,851
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,271
Amount paid for insurance broker fees1801
Additional information about fees paid to insurance brokerBONUS
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberVDT962204
Policy instance 12
Insurance contract or identification numberVDT962204
Number of Individuals Covered3274
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $6,241
Total amount of fees paid to insurance companyUSD $20,000
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $249,630
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6,241
Amount paid for insurance broker fees20000
Additional information about fees paid to insurance brokerBONUS
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberLK 965146
Policy instance 10
Insurance contract or identification numberLK 965146
Number of Individuals Covered5293
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $7,544
Total amount of fees paid to insurance companyUSD $20,000
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $301,744
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $7,544
Amount paid for insurance broker fees20000
Additional information about fees paid to insurance brokerBONUS
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberFLX967522
Policy instance 9
Insurance contract or identification numberFLX967522
Number of Individuals Covered5293
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $1,724
Total amount of fees paid to insurance companyUSD $8,198
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $69,017
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,724
Amount paid for insurance broker fees8198
Additional information about fees paid to insurance brokerBONUS
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberAI 960282
Policy instance 11
Insurance contract or identification numberAI 960282
Number of Individuals Covered1553
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $73,567
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedACCIDENTAL INJURY
Welfare Benefit Premiums Paid to CarrierUSD $342,378
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $73,567
Insurance broker organization code?3
OREGON DENTAL SERVICE (National Association of Insurance Commissioners NAIC id number: 54941 )
Policy contract number10000122
Policy instance 1
Insurance contract or identification number10000122
Number of Individuals Covered2838
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $3,331,245
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Insurance broker organization code?3
WILLAMETTE DENTAL INSURANCE, INC. (National Association of Insurance Commissioners NAIC id number: 57069 )
Policy contract numberOR134/OR135
Policy instance 2
Insurance contract or identification numberOR134/OR135
Number of Individuals Covered2166
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberCI 960295
Policy instance 3
Insurance contract or identification numberCI 960295
Number of Individuals Covered1726
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $83,627
Total amount of fees paid to insurance companyUSD $7,942
Other welfare benefits providedCRITICAL ILLNESS
Welfare Benefit Premiums Paid to CarrierUSD $453,611
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $83,627
Amount paid for insurance broker fees7942
Additional information about fees paid to insurance brokerBONUS
Insurance broker organization code?3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number091135
Policy instance 4
Insurance contract or identification number091135
Number of Individuals Covered471
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $22,782
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedLONG TERM CARE
Welfare Benefit Premiums Paid to CarrierUSD $148,076
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $22,782
Insurance broker organization code?3
ACE AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 22667 )
Policy contract numberADD N04224310
Policy instance 5
Insurance contract or identification numberADD N04224310
Number of Individuals Covered612
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $285
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedACCIDENTAL DEATH
Welfare Benefit Premiums Paid to CarrierUSD $1,900
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $285
Insurance broker organization code?3
PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )
Policy contract number0008461032
Policy instance 6
Insurance contract or identification number0008461032
Number of Individuals Covered409
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $6,596
Total amount of fees paid to insurance companyUSD $0
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $139,505
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,327
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberOK 969196
Policy instance 8
Insurance contract or identification numberOK 969196
Number of Individuals Covered1876
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $3,802
Total amount of fees paid to insurance companyUSD $2,746
Other welfare benefits providedACCIDENTAL DEATH
Welfare Benefit Premiums Paid to CarrierUSD $152,092
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,802
Amount paid for insurance broker fees2746
Additional information about fees paid to insurance brokerBONUS
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberFLX967522
Policy instance 9
Insurance contract or identification numberFLX967522
Number of Individuals Covered5308
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $10,241
Total amount of fees paid to insurance companyUSD $7,585
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $409,884
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $10,241
Amount paid for insurance broker fees7585
Additional information about fees paid to insurance brokerBONUS
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberFLX967685
Policy instance 7
Insurance contract or identification numberFLX967685
Number of Individuals Covered3721
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $33,519
Total amount of fees paid to insurance companyUSD $20,037
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,342,122
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $33,519
Amount paid for insurance broker fees20037
Additional information about fees paid to insurance brokerBONUS
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberLK 752070
Policy instance 14
Insurance contract or identification numberLK 752070
Number of Individuals Covered471
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $9,702
Total amount of fees paid to insurance companyUSD $7,637
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $388,098
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $9,702
Amount paid for insurance broker fees7637
Additional information about fees paid to insurance brokerBONUS
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberOK 969031
Policy instance 13
Insurance contract or identification numberOK 969031
Number of Individuals Covered5308
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $2,257
Total amount of fees paid to insurance companyUSD $1,672
Other welfare benefits providedACCIDENTAL DEATH
Welfare Benefit Premiums Paid to CarrierUSD $90,270
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,257
Amount paid for insurance broker fees1672
Additional information about fees paid to insurance brokerBONUS
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberVDT962204
Policy instance 12
Insurance contract or identification numberVDT962204
Number of Individuals Covered3449
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $37,879
Total amount of fees paid to insurance companyUSD $20,000
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,515,141
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $37,879
Amount paid for insurance broker fees20000
Additional information about fees paid to insurance brokerBONUS
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberAI 960282
Policy instance 11
Insurance contract or identification numberAI 960282
Number of Individuals Covered1466
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $66,128
Total amount of fees paid to insurance companyUSD $6,101
Other welfare benefits providedACCIDENTAL INJURY
Welfare Benefit Premiums Paid to CarrierUSD $325,589
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $60,026
Amount paid for insurance broker fees6101
Additional information about fees paid to insurance brokerBONUS
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberLK 965146
Policy instance 10
Insurance contract or identification numberLK 965146
Number of Individuals Covered5317
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $44,791
Total amount of fees paid to insurance companyUSD $20,000
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,791,653
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $44,791
Amount paid for insurance broker fees20000
Additional information about fees paid to insurance brokerBONUS
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberOK 969031
Policy instance 13
Insurance contract or identification numberOK 969031
Number of Individuals Covered5298
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $2,485
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedACCIDENTAL DEATH
Welfare Benefit Premiums Paid to CarrierUSD $99,400
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,485
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberVDT962204
Policy instance 12
Insurance contract or identification numberVDT962204
Number of Individuals Covered3446
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $40,738
Total amount of fees paid to insurance companyUSD $0
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,629,537
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $40,738
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberAI 960282
Policy instance 11
Insurance contract or identification numberAI 960282
Number of Individuals Covered1264
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $66,191
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedACCIDENTAL INJURY
Welfare Benefit Premiums Paid to CarrierUSD $281,860
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $66,191
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberLK 965146
Policy instance 10
Insurance contract or identification numberLK 965146
Number of Individuals Covered5274
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $48,179
Total amount of fees paid to insurance companyUSD $0
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,927,169
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $48,179
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberFLX967522
Policy instance 9
Insurance contract or identification numberFLX967522
Number of Individuals Covered5298
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $11,312
Total amount of fees paid to insurance companyUSD $0
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $455,293
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $11,312
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberFLX967685
Policy instance 7
Insurance contract or identification numberFLX967685
Number of Individuals Covered3468
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $31,674
Total amount of fees paid to insurance companyUSD $0
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,268,821
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $31,674
Insurance broker organization code?3
PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )
Policy contract number0008461032
Policy instance 6
Insurance contract or identification number0008461032
Number of Individuals Covered438
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $5,932
Total amount of fees paid to insurance companyUSD $0
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $137,604
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,573
Insurance broker organization code?3
ACE AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 22667 )
Policy contract numberADD N04224310
Policy instance 5
Insurance contract or identification numberADD N04224310
Number of Individuals Covered612
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $307
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedACCIDENTAL DEATH
Welfare Benefit Premiums Paid to CarrierUSD $1,900
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $307
Insurance broker organization code?3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number091135
Policy instance 4
Insurance contract or identification number091135
Number of Individuals Covered529
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $22,711
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedLONG TERM CARE
Welfare Benefit Premiums Paid to CarrierUSD $145,336
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $22,711
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberCI 960295
Policy instance 3
Insurance contract or identification numberCI 960295
Number of Individuals Covered1666
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $84,184
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedCRITICAL ILLNESS
Welfare Benefit Premiums Paid to CarrierUSD $366,249
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $84,184
Insurance broker organization code?3
OREGON DENTAL SERVICE (National Association of Insurance Commissioners NAIC id number: 54941 )
Policy contract number10000122
Policy instance 1
Insurance contract or identification number10000122
Number of Individuals Covered2788
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $3,730,656
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberLK 752070
Policy instance 14
Insurance contract or identification numberLK 752070
Number of Individuals Covered472
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $10,212
Total amount of fees paid to insurance companyUSD $0
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $408,466
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $10,212
Insurance broker organization code?3
WILLAMETTE DENTAL INSURANCE, INC. (National Association of Insurance Commissioners NAIC id number: 57069 )
Policy contract numberOR134/OR135
Policy instance 2
Insurance contract or identification numberOR134/OR135
Number of Individuals Covered2300
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberOK 969196
Policy instance 8
Insurance contract or identification numberOK 969196
Number of Individuals Covered1763
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $4,047
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedACCIDENTAL DEATH
Welfare Benefit Premiums Paid to CarrierUSD $161,868
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,047
Insurance broker organization code?3
WILLAMETTE DENTAL INSURANCE, INC. (National Association of Insurance Commissioners NAIC id number: 57069 )
Policy contract numberOR134/OR135
Policy instance 2
Insurance contract or identification number704808
Number of Individuals Covered2377
Insurance policy start date2010-01-01
Insurance policy end date2010-12-31
Total amount of commissions paid to insurance brokerUSD $233,203
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $1,361,843
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberOK 969031
Policy instance 13
Insurance contract or identification numberOK 969031
Number of Individuals Covered5467
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $1,917
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedACCIDENTAL DEATH
Welfare Benefit Premiums Paid to CarrierUSD $76,680
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,917
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberVDT962204
Policy instance 12
Insurance contract or identification numberVDT962204
Number of Individuals Covered3587
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $30,777
Total amount of fees paid to insurance companyUSD $0
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,231,076
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $30,777
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberLK 965146
Policy instance 10
Insurance contract or identification numberLK 965146
Number of Individuals Covered5443
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $36,320
Total amount of fees paid to insurance companyUSD $0
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,452,782
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $36,320
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberFLX967522
Policy instance 9
Insurance contract or identification numberFLX967522
Number of Individuals Covered5467
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $8,767
Total amount of fees paid to insurance companyUSD $0
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $350,678
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $8,767
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberAI 960282
Policy instance 11
Insurance contract or identification numberAI 960282
Number of Individuals Covered1356
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $58,452
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedACCIDENTAL INJURY
Welfare Benefit Premiums Paid to CarrierUSD $292,258
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $58,452
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberOK 969196
Policy instance 8
Insurance contract or identification numberOK 969196
Number of Individuals Covered1819
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $3,121
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedACCIDENTAL DEATH
Welfare Benefit Premiums Paid to CarrierUSD $124,855
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,121
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberFLX967685
Policy instance 7
Insurance contract or identification numberFLX967685
Number of Individuals Covered3338
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $22,099
Total amount of fees paid to insurance companyUSD $0
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $883,972
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $22,099
Insurance broker organization code?3
PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )
Policy contract number0008461032
Policy instance 6
Insurance contract or identification number0008461032
Number of Individuals Covered430
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $4,434
Total amount of fees paid to insurance companyUSD $0
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $127,065
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,538
Insurance broker organization code?3
ACE AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 22667 )
Policy contract numberADD N04224310
Policy instance 5
Insurance contract or identification numberADD N04224310
Number of Individuals Covered612
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $285
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedACCIDENTAL DEATH
Welfare Benefit Premiums Paid to CarrierUSD $1,900
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $285
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberCI 960295
Policy instance 3
Insurance contract or identification numberCI 960295
Number of Individuals Covered1412
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $65,465
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedCRITICAL ILLNESS
Welfare Benefit Premiums Paid to CarrierUSD $327,323
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $65,465
Insurance broker organization code?3
OREGON DENTAL SERVICE (National Association of Insurance Commissioners NAIC id number: 54941 )
Policy contract number10000122
Policy instance 1
Insurance contract or identification number10000122
Number of Individuals Covered2812
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $3,557,719
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberLK 752070
Policy instance 14
Insurance contract or identification numberLK 752070
Number of Individuals Covered462
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $7,550
Total amount of fees paid to insurance companyUSD $0
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $301,997
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $7,550
Insurance broker organization code?3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number091135
Policy instance 4
Insurance contract or identification number091135
Number of Individuals Covered437
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $23,222
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedLONG TERM CARE
Welfare Benefit Premiums Paid to CarrierUSD $152,657
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $23,222
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberLK 752070
Policy instance 14
Insurance contract or identification numberLK 752070
Number of Individuals Covered449
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $28,196
Total amount of fees paid to insurance companyUSD $0
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $326,749
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $28,196
Insurance broker organization code?3
Insurance broker nameTIMOTHY HENNESSY
OREGON DENTAL SERVICE (National Association of Insurance Commissioners NAIC id number: 54941 )
Policy contract number10000122
Policy instance 1
Insurance contract or identification number10000122
Number of Individuals Covered2724
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $19,588
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $3,221,927
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $19,588
Insurance broker organization code?3
Insurance broker nameTIMOTHY HENNESSY
WILLAMETTE DENTAL INSURANCE, INC. (National Association of Insurance Commissioners NAIC id number: 57069 )
Policy contract numberOR134/Z969
Policy instance 2
Insurance contract or identification numberOR134/Z969
Number of Individuals Covered2483
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $38,796
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $38,796
Insurance broker organization code?3
Insurance broker nameTIMOTHY HENNESSY
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberCI 960295
Policy instance 3
Insurance contract or identification numberCI 960295
Number of Individuals Covered1513
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $81,790
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedCRITICAL ILLNESS
Welfare Benefit Premiums Paid to CarrierUSD $304,180
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $81,790
Insurance broker organization code?3
Insurance broker nameTIMOTHY HENNESSY
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number091135
Policy instance 4
Insurance contract or identification number091135
Number of Individuals Covered432
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $22,148
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedLONG TERM CARE
Welfare Benefit Premiums Paid to CarrierUSD $156,308
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $22,148
Insurance broker organization code?3
Insurance broker nameTIMOTHY HENNESSY
ACE AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 22667 )
Policy contract numberADD N04224310
Policy instance 5
Insurance contract or identification numberADD N04224310
Number of Individuals Covered316
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $285
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedACCIDENTAL DEATH
Welfare Benefit Premiums Paid to CarrierUSD $1,900
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $285
Insurance broker organization code?3
Insurance broker nameBARKER-UERLINGS INSURANCE
PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )
Policy contract number0008461032
Policy instance 6
Insurance contract or identification number0008461032
Number of Individuals Covered448
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $7,564
Total amount of fees paid to insurance companyUSD $0
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $147,351
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,978
Insurance broker organization code?3
Insurance broker nameCUSTOM BENEFIT PROGRAMS INC.
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberFLX967685
Policy instance 7
Insurance contract or identification numberFLX967685
Number of Individuals Covered3429
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $72,370
Total amount of fees paid to insurance companyUSD $0
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $894,797
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $72,370
Insurance broker organization code?3
Insurance broker nameTIMOTHY HENNESSY
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberOK 969196
Policy instance 8
Insurance contract or identification numberOK 969196
Number of Individuals Covered1840
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $12,552
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedACCIDENTAL DEATH
Welfare Benefit Premiums Paid to CarrierUSD $137,247
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $12,552
Insurance broker organization code?3
Insurance broker nameTIMOTHY HENNESSY
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberOK 969031
Policy instance 13
Insurance contract or identification numberOK 969031
Number of Individuals Covered5480
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $7,709
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedACCIDENTAL DEATH
Welfare Benefit Premiums Paid to CarrierUSD $86,007
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $7,709
Insurance broker organization code?3
Insurance broker nameTIMOTHY HENNESSY
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberVDT962204
Policy instance 12
Insurance contract or identification numberVDT962204
Number of Individuals Covered3539
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $81,784
Total amount of fees paid to insurance companyUSD $0
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,271,372
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $81,784
Insurance broker organization code?3
Insurance broker nameTIMOTHY HENNESSY
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberAI 960282
Policy instance 11
Insurance contract or identification numberAI 960282
Number of Individuals Covered1355
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $65,020
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedACCIDENTAL DEATH
Welfare Benefit Premiums Paid to CarrierUSD $241,546
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $65,020
Insurance broker organization code?3
Insurance broker nameTIMOTHY HENNESSY
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberLK 965146
Policy instance 10
Insurance contract or identification numberLK 965146
Number of Individuals Covered5455
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $87,328
Total amount of fees paid to insurance companyUSD $0
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,493,118
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $87,328
Insurance broker organization code?3
Insurance broker nameTIMOTHY HENNESSY
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberFLX967522
Policy instance 9
Insurance contract or identification numberFLX967522
Number of Individuals Covered5480
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $35,355
Total amount of fees paid to insurance companyUSD $0
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $394,161
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $35,355
Insurance broker organization code?3
Insurance broker nameTIMOTHY HENNESSY
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number000010164310
Policy instance 10
Insurance contract or identification number000010164310
Number of Individuals Covered4969
Insurance policy start date2015-01-01
Insurance policy end date2015-12-31
Total amount of commissions paid to insurance brokerUSD $86,642
Total amount of fees paid to insurance companyUSD $0
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,332,843
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $86,642
Insurance broker organization code?3
Insurance broker nameTIMOTHY HENNESSY
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number000010164309
Policy instance 9
Insurance contract or identification number000010164309
Number of Individuals Covered4997
Insurance policy start date2015-01-01
Insurance policy end date2015-12-31
Total amount of commissions paid to insurance brokerUSD $47,396
Total amount of fees paid to insurance companyUSD $0
Life Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH
Welfare Benefit Premiums Paid to CarrierUSD $476,807
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $47,396
Insurance broker organization code?3
Insurance broker nameTIMOTHY HENNESSY
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number000403001843
Policy instance 8
Insurance contract or identification number000403001843
Number of Individuals Covered1721
Insurance policy start date2015-01-01
Insurance policy end date2015-12-31
Total amount of commissions paid to insurance brokerUSD $11,936
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedACCIDENTAL DEATH
Welfare Benefit Premiums Paid to CarrierUSD $119,934
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $11,936
Insurance broker organization code?3
Insurance broker nameTIMOTHY HENNESSY
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number000400001000
Policy instance 7
Insurance contract or identification number000400001000
Number of Individuals Covered2401
Insurance policy start date2015-01-01
Insurance policy end date2015-12-31
Total amount of commissions paid to insurance brokerUSD $49,569
Total amount of fees paid to insurance companyUSD $0
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $591,371
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $49,569
Insurance broker organization code?3
Insurance broker nameTIMOTHY HENNESSY
PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )
Policy contract number0008461032
Policy instance 6
Insurance contract or identification number0008461032
Number of Individuals Covered513
Insurance policy start date2015-01-01
Insurance policy end date2015-12-31
Total amount of commissions paid to insurance brokerUSD $8,415
Total amount of fees paid to insurance companyUSD $18
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $163,313
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,339
Insurance broker organization code?3
Amount paid for insurance broker fees18
Insurance broker nameCUSTOM BENEFIT PROGRAMS INC
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number091135
Policy instance 4
Insurance contract or identification number091135
Number of Individuals Covered438
Insurance policy start date2015-01-01
Insurance policy end date2015-12-31
Total amount of commissions paid to insurance brokerUSD $23,166
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedLONG TERM CARE
Welfare Benefit Premiums Paid to CarrierUSD $156,538
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $23,166
Insurance broker organization code?3
Insurance broker nameTIMOTHY HENNESSY
LIFEMAP ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 97985 )
Policy contract numberWBT0000474
Policy instance 3
Insurance contract or identification numberWBT0000474
Number of Individuals Covered504
Insurance policy start date2015-01-01
Insurance policy end date2015-12-31
Total amount of commissions paid to insurance brokerUSD $85,073
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedCRITICAL ILLNESS
Welfare Benefit Premiums Paid to CarrierUSD $465,074
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $85,073
Insurance broker organization code?3
Insurance broker nameTIMOTHY HENNESSY
WILLAMETTE DENTAL INSURANCE, INC. (National Association of Insurance Commissioners NAIC id number: 57069 )
Policy contract numberZ969
Policy instance 2
Insurance contract or identification numberZ969
Number of Individuals Covered2238
Insurance policy start date2015-01-01
Insurance policy end date2015-12-31
Total amount of commissions paid to insurance brokerUSD $56,271
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $56,271
Insurance broker organization code?3
Insurance broker nameTIMOTHY HENNESSY
OREGON DENTAL SERVICE (National Association of Insurance Commissioners NAIC id number: 54941 )
Policy contract number10000122
Policy instance 1
Insurance contract or identification number10000122
Number of Individuals Covered2431
Insurance policy start date2015-01-01
Insurance policy end date2015-12-31
Total amount of commissions paid to insurance brokerUSD $27,109
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $2,938,022
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $27,109
Insurance broker organization code?3
Insurance broker nameTIMOTHY HENNESSY
ACE AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 22667 )
Policy contract numberADD N04224310
Policy instance 5
Insurance contract or identification numberADD N04224310
Number of Individuals Covered316
Insurance policy start date2015-01-01
Insurance policy end date2015-12-31
Total amount of commissions paid to insurance brokerUSD $285
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedACCIDENTAL DEATH
Welfare Benefit Premiums Paid to CarrierUSD $1,900
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $285
Insurance broker organization code?3
Insurance broker nameBARKER-UERLINGS INSURANCE
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number000010164311
Policy instance 11
Insurance contract or identification number000010164311
Number of Individuals Covered390
Insurance policy start date2015-01-01
Insurance policy end date2015-12-31
Total amount of commissions paid to insurance brokerUSD $24,785
Total amount of fees paid to insurance companyUSD $0
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $250,221
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $24,785
Insurance broker organization code?3
Insurance broker nameTIMOTHY HENNESSY
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number000010165518
Policy instance 12
Insurance contract or identification number000010165518
Number of Individuals Covered2544
Insurance policy start date2015-01-01
Insurance policy end date2015-12-31
Total amount of commissions paid to insurance brokerUSD $73,795
Total amount of fees paid to insurance companyUSD $0
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,075,901
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $73,795
Insurance broker organization code?3
Insurance broker nameTIMOTHY HENNESSY
OREGON DENTAL SERVICE (National Association of Insurance Commissioners NAIC id number: 54941 )
Policy contract number10000122
Policy instance 1
Insurance contract or identification number10000122
Number of Individuals Covered2271
Insurance policy start date2014-01-01
Insurance policy end date2014-12-31
Total amount of commissions paid to insurance brokerUSD $25,541
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $2,235,571
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $25,541
Insurance broker organization code?3
Insurance broker nameTIMOTHY HENNESSY
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number000010164311
Policy instance 11
Insurance contract or identification number000010164311
Number of Individuals Covered376
Insurance policy start date2014-01-01
Insurance policy end date2014-12-31
Total amount of commissions paid to insurance brokerUSD $23,892
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $306,850
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $23,892
Insurance broker organization code?3
Insurance broker nameTIMOTHY HENNESSY
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number000010164309
Policy instance 9
Insurance contract or identification number000010164309
Number of Individuals Covered4704
Insurance policy start date2014-01-01
Insurance policy end date2014-12-31
Total amount of commissions paid to insurance brokerUSD $46,503
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Life Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH
Welfare Benefit Premiums Paid to CarrierUSD $588,885
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $46,503
Insurance broker organization code?3
Insurance broker nameTIMOTHY HENNESSY
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number000010164310
Policy instance 10
Insurance contract or identification number000010164310
Number of Individuals Covered4678
Insurance policy start date2014-01-01
Insurance policy end date2014-12-31
Total amount of commissions paid to insurance brokerUSD $98,197
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,563,932
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $98,197
Insurance broker organization code?3
Insurance broker nameTIMOTHY HENNESSY
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number000403001843
Policy instance 8
Insurance contract or identification number000403001843
Number of Individuals Covered1684
Insurance policy start date2014-01-01
Insurance policy end date2014-12-31
Total amount of commissions paid to insurance brokerUSD $11,829
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Other welfare benefits providedACCIDENTAL DEATH
Welfare Benefit Premiums Paid to CarrierUSD $148,485
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $11,829
Insurance broker organization code?3
Insurance broker nameTIMOTHY HENNESSY
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number000400001000
Policy instance 7
Insurance contract or identification number000400001000
Number of Individuals Covered1969
Insurance policy start date2014-01-01
Insurance policy end date2014-12-31
Total amount of commissions paid to insurance brokerUSD $43,830
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $604,531
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $43,830
Insurance broker organization code?3
Insurance broker nameTIMOTHY HENNESSY
PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )
Policy contract number0008461032
Policy instance 6
Insurance contract or identification number0008461032
Number of Individuals Covered579
Insurance policy start date2014-01-01
Insurance policy end date2014-12-31
Total amount of commissions paid to insurance brokerUSD $9,464
Total amount of fees paid to insurance companyUSD $20
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $189,024
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,734
Insurance broker organization code?3
Amount paid for insurance broker fees20
Insurance broker nameCUSTOM BENEFIT PROGRAMS INC
ACE AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 22667 )
Policy contract numberADD N04224310
Policy instance 5
Insurance contract or identification numberADD N04224310
Number of Individuals Covered316
Insurance policy start date2014-01-01
Insurance policy end date2014-12-31
Total amount of commissions paid to insurance brokerUSD $285
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Other welfare benefits providedACCIDENTAL DEATH
Welfare Benefit Premiums Paid to CarrierUSD $1,900
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $285
Insurance broker organization code?3
Insurance broker nameBARKER-UERLINGS INSURANCE
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number091135
Policy instance 4
Insurance contract or identification number091135
Number of Individuals Covered422
Insurance policy start date2014-01-01
Insurance policy end date2014-12-31
Total amount of commissions paid to insurance brokerUSD $26,828
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Other welfare benefits providedLONG TERM CARE
Welfare Benefit Premiums Paid to CarrierUSD $163,920
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $26,828
Insurance broker organization code?3
Insurance broker nameTIMOTHY HENNESSY
WILLAMETTE DENTAL INSURANCE, INC. (National Association of Insurance Commissioners NAIC id number: 57069 )
Policy contract numberZ969
Policy instance 2
Insurance contract or identification numberZ969
Number of Individuals Covered2073
Insurance policy start date2014-01-01
Insurance policy end date2014-12-31
Total amount of commissions paid to insurance brokerUSD $50,787
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Dental Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $50,787
Insurance broker organization code?3
Insurance broker nameTIMOTHY HENNESSY
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number000010165518
Policy instance 12
Insurance contract or identification number000010165518
Number of Individuals Covered2442
Insurance policy start date2014-01-01
Insurance policy end date2014-12-31
Total amount of commissions paid to insurance brokerUSD $86,631
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,332,626
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $86,631
Insurance broker organization code?3
Insurance broker nameTIMOTHY HENNESSY
LIFEMAP ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 97985 )
Policy contract numberWBT0000474
Policy instance 3
Insurance contract or identification numberWBT0000474
Number of Individuals Covered554
Insurance policy start date2014-01-01
Insurance policy end date2014-12-31
Total amount of commissions paid to insurance brokerUSD $91,925
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Other welfare benefits providedCRITICAL ILLNESS
Welfare Benefit Premiums Paid to CarrierUSD $494,017
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $91,925
Insurance broker organization code?3
Insurance broker nameTIMOTHY HENNESSY
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number000010164310
Policy instance 10
Insurance contract or identification number000010164310
Number of Individuals Covered4440
Insurance policy start date2013-01-01
Insurance policy end date2013-12-31
Total amount of commissions paid to insurance brokerUSD $53,893
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,077,863
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $53,893
Insurance broker organization code?3
Insurance broker nameTIMOTHY HENNESSY
WILLAMETTE DENTAL INSURANCE, INC. (National Association of Insurance Commissioners NAIC id number: 57069 )
Policy contract numberZ969
Policy instance 2
Insurance contract or identification numberZ969
Number of Individuals Covered1999
Insurance policy start date2013-01-01
Insurance policy end date2013-12-31
Total amount of commissions paid to insurance brokerUSD $47,950
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Dental Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $47,950
Insurance broker organization code?3
Insurance broker nameTIMOTHY HENNESSY
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number000010165518
Policy instance 12
Insurance contract or identification number000010165518
Number of Individuals Covered2445
Insurance policy start date2013-01-01
Insurance policy end date2013-12-31
Total amount of commissions paid to insurance brokerUSD $65,578
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $981,636
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $65,578
Insurance broker organization code?3
Insurance broker nameTIMOTHY HENNESSY
LIFEMAP ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 97985 )
Policy contract numberWBT0000474
Policy instance 3
Insurance contract or identification numberWBT0000474
Number of Individuals Covered960
Insurance policy start date2013-01-01
Insurance policy end date2013-12-31
Total amount of commissions paid to insurance brokerUSD $83,826
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedCRITICAL ILLNESS
Welfare Benefit Premiums Paid to CarrierUSD $980,490
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $83,826
Insurance broker organization code?3
Insurance broker nameTIMOTHY HENNESSY
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number091135
Policy instance 4
Insurance contract or identification number091135
Number of Individuals Covered434
Insurance policy start date2013-01-01
Insurance policy end date2013-12-31
Total amount of commissions paid to insurance brokerUSD $26,643
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Other welfare benefits providedLONG TERM CARE
Welfare Benefit Premiums Paid to CarrierUSD $195,278
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $26,643
Insurance broker organization code?3
Insurance broker nameTIMOTHY HENNESSY
ACE AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 22667 )
Policy contract numberADD N04224310
Policy instance 5
Insurance contract or identification numberADD N04224310
Number of Individuals Covered280
Insurance policy start date2013-01-01
Insurance policy end date2013-12-31
Total amount of commissions paid to insurance brokerUSD $285
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Other welfare benefits providedACCIDENTAL DEATH
Welfare Benefit Premiums Paid to CarrierUSD $1,900
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $285
Insurance broker organization code?3
Insurance broker nameBARKER-UERLINGS INSURANCE
PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )
Policy contract number0008461032
Policy instance 6
Insurance contract or identification number0008461032
Number of Individuals Covered662
Insurance policy start date2013-01-01
Insurance policy end date2013-12-31
Total amount of commissions paid to insurance brokerUSD $11,303
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $217,978
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,653
Insurance broker organization code?3
Insurance broker nameCUSTOM BENEFIT PROGRAMS INC
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number000400001000
Policy instance 7
Insurance contract or identification number000400001000
Number of Individuals Covered1057
Insurance policy start date2013-01-01
Insurance policy end date2013-12-31
Total amount of commissions paid to insurance brokerUSD $42,628
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $340,083
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $42,628
Insurance broker organization code?3
Insurance broker nameTIMOTHY HENNESSY
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number000403001843
Policy instance 8
Insurance contract or identification number000403001843
Number of Individuals Covered1667
Insurance policy start date2013-01-01
Insurance policy end date2013-12-31
Total amount of commissions paid to insurance brokerUSD $30,506
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Other welfare benefits providedACCIDENTAL DEATH
Welfare Benefit Premiums Paid to CarrierUSD $110,123
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $30,506
Insurance broker organization code?3
Insurance broker nameTIMOTHY HENNESSY
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number000010164309
Policy instance 9
Insurance contract or identification number000010164309
Number of Individuals Covered4498
Insurance policy start date2013-01-01
Insurance policy end date2013-12-31
Total amount of commissions paid to insurance brokerUSD $43,184
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Life Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH
Welfare Benefit Premiums Paid to CarrierUSD $426,461
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $43,184
Insurance broker organization code?3
Insurance broker nameTIMOTHY HENNESSY
OREGON DENTAL SERVICE (National Association of Insurance Commissioners NAIC id number: 54941 )
Policy contract number10000122
Policy instance 1
Insurance contract or identification number10000122
Number of Individuals Covered2217
Insurance policy start date2013-01-01
Insurance policy end date2013-12-31
Total amount of commissions paid to insurance brokerUSD $30,028
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $2,374,983
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $30,028
Insurance broker organization code?3
Insurance broker nameTIMOTHY HENNESSY
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number000010164311
Policy instance 11
Insurance contract or identification number000010164311
Number of Individuals Covered361
Insurance policy start date2013-01-01
Insurance policy end date2013-12-31
Total amount of commissions paid to insurance brokerUSD $35,687
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $213,744
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $35,687
Insurance broker organization code?3
Insurance broker nameTIMOTHY HENNESSY
WILLAMETTE DENTAL INSURANCE, INC. (National Association of Insurance Commissioners NAIC id number: 57069 )
Policy contract numberZ969
Policy instance 2
Insurance contract or identification numberZ969
Number of Individuals Covered1926
Insurance policy start date2012-01-01
Insurance policy end date2012-12-31
Total amount of commissions paid to insurance brokerUSD $52,287
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Dental Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $52,287
Insurance broker organization code?3
Insurance broker nameTIMOTHY HENNESSY
LIFEMAP ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 97985 )
Policy contract numberWBT000474
Policy instance 3
Insurance contract or identification numberWBT000474
Number of Individuals Covered4499
Insurance policy start date2012-01-01
Insurance policy end date2012-12-31
Total amount of commissions paid to insurance brokerUSD $275,086
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $3,509,118
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $275,086
Insurance broker organization code?3
Insurance broker nameTIMOTHY HENNESSY
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number091135
Policy instance 4
Insurance contract or identification number091135
Number of Individuals Covered424
Insurance policy start date2012-01-01
Insurance policy end date2012-12-31
Total amount of commissions paid to insurance brokerUSD $23,414
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Other welfare benefits providedLONG TERM CARE
Welfare Benefit Premiums Paid to CarrierUSD $157,500
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $23,414
Insurance broker organization code?3
Insurance broker nameTIMOTHY HENNESSY
ACE AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 22667 )
Policy contract numberADD N04224310
Policy instance 5
Insurance contract or identification numberADD N04224310
Number of Individuals Covered280
Insurance policy start date2012-01-01
Insurance policy end date2012-12-31
Total amount of commissions paid to insurance brokerUSD $285
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Other welfare benefits providedACCIDENTAL DEATH
Welfare Benefit Premiums Paid to CarrierUSD $1,900
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $285
Insurance broker organization code?3
Insurance broker nameBARKER-UERLINGS INSURANCE
PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )
Policy contract number0008461032
Policy instance 6
Insurance contract or identification number0008461032
Number of Individuals Covered874
Insurance policy start date2012-01-01
Insurance policy end date2012-12-31
Total amount of commissions paid to insurance brokerUSD $14,602
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $248,396
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $7,301
Insurance broker organization code?3
Insurance broker nameCUSTOM BENEFIT PROGRAMS INC
OREGON DENTAL SERVICE (National Association of Insurance Commissioners NAIC id number: 54941 )
Policy contract number10000122
Policy instance 1
Insurance contract or identification number10000122
Number of Individuals Covered2424
Insurance policy start date2012-01-01
Insurance policy end date2012-12-31
Total amount of commissions paid to insurance brokerUSD $29,599
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $2,473,836
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $29,599
Insurance broker organization code?3
Insurance broker nameTIMOTHY HENNESSY
OREGON DENTAL SERVICE (National Association of Insurance Commissioners NAIC id number: 54941 )
Policy contract number10000122
Policy instance 1
Insurance contract or identification number10000122
Number of Individuals Covered2462
Insurance policy start date2011-01-01
Insurance policy end date2011-12-31
Total amount of commissions paid to insurance brokerUSD $30,020
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $2,473,528
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )
Policy contract number0000008461032
Policy instance 6
Insurance contract or identification number0000008461032
Number of Individuals Covered2360
Insurance policy start date2011-01-01
Insurance policy end date2011-12-31
Total amount of commissions paid to insurance brokerUSD $21,364
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $395,038
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
WILLAMETTE DENTAL INSURANCE, INC. (National Association of Insurance Commissioners NAIC id number: 57069 )
Policy contract numberZ969
Policy instance 2
Insurance contract or identification numberZ969
Number of Individuals Covered1930
Insurance policy start date2011-01-01
Insurance policy end date2011-12-31
Total amount of commissions paid to insurance brokerUSD $55,097
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Dental Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number091135
Policy instance 4
Insurance contract or identification number091135
Number of Individuals Covered421
Insurance policy start date2011-01-01
Insurance policy end date2011-12-31
Total amount of commissions paid to insurance brokerUSD $20,236
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Other welfare benefits providedLONG TERM CARE
Welfare Benefit Premiums Paid to CarrierUSD $134,003
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
ACE AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 22667 )
Policy contract numberADD N04224310
Policy instance 5
Insurance contract or identification numberADD N04224310
Number of Individuals Covered185
Insurance policy start date2011-01-01
Insurance policy end date2011-12-31
Total amount of commissions paid to insurance brokerUSD $285
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Other welfare benefits providedACCIDENTAL DEATH
Welfare Benefit Premiums Paid to CarrierUSD $1,900
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
LIFEMAP ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 97985 )
Policy contract numberWBT000474
Policy instance 3
Insurance contract or identification numberWBT000474
Number of Individuals Covered4601
Insurance policy start date2011-01-01
Insurance policy end date2011-12-31
Total amount of commissions paid to insurance brokerUSD $336,144
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $3,811,969
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
ACE AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 22667 )
Policy contract numberADD N04224310
Policy instance 1
Insurance contract or identification numberADD N04224310
Number of Individuals Covered264
Insurance policy start date2010-01-01
Insurance policy end date2010-12-31
Total amount of commissions paid to insurance brokerUSD $285
Other welfare benefits providedACCIDENTAL DEATH
Welfare Benefit Premiums Paid to CarrierUSD $1,900
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
OREGON DENTAL SERVICE (National Association of Insurance Commissioners NAIC id number: 54941 )
Policy contract number10000122
Policy instance 5
Insurance contract or identification number10000122
Number of Individuals Covered2458
Insurance policy start date2010-01-01
Insurance policy end date2010-12-31
Total amount of commissions paid to insurance brokerUSD $29,480
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $2,235,283
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number091135
Policy instance 2
Insurance contract or identification number091135
Number of Individuals Covered381
Insurance policy start date2010-01-01
Insurance policy end date2010-12-31
Total amount of commissions paid to insurance brokerUSD $18,476
Other welfare benefits providedLONG TERM CARE
Welfare Benefit Premiums Paid to CarrierUSD $123,171
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
WILLAMETTE DENTAL INSURANCE, INC. (National Association of Insurance Commissioners NAIC id number: 57069 )
Policy contract numberZ969
Policy instance 4
Insurance contract or identification numberZ969
Number of Individuals Covered1836
Insurance policy start date2010-01-01
Insurance policy end date2010-12-31
Total amount of commissions paid to insurance brokerUSD $54,034
Dental Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
LIFEMAP ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 97985 )
Policy contract numberWBT000474
Policy instance 3
Insurance contract or identification numberWBT000474
Number of Individuals Covered4638
Insurance policy start date2010-01-01
Insurance policy end date2010-12-31
Total amount of commissions paid to insurance brokerUSD $160,666
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $3,215,518
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No

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