DECORE-ATIVE SPECIALTIES INC has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan DECORE-ATIVE SPECIALTIES, INC. GROUP LIFE AND HEALTH INSURANCE PLAN
401k plan membership statisitcs for DECORE-ATIVE SPECIALTIES, INC. GROUP LIFE AND HEALTH INSURANCE PLAN
| Measure | Date | Value |
|---|
| 2022: DECORE-ATIVE SPECIALTIES, INC. GROUP LIFE AND HEALTH INSURANCE PLAN 2022 401k membership |
|---|
| Total participants, beginning-of-year | 2022-06-01 | 747 |
| Total number of active participants reported on line 7a of the Form 5500 | 2022-06-01 | 723 |
| Number of retired or separated participants receiving benefits | 2022-06-01 | 1 |
| Number of other retired or separated participants entitled to future benefits | 2022-06-01 | 0 |
| Total of all active and inactive participants | 2022-06-01 | 724 |
| Number of employers contributing to the scheme | 2022-06-01 | 0 |
| 2021: DECORE-ATIVE SPECIALTIES, INC. GROUP LIFE AND HEALTH INSURANCE PLAN 2021 401k membership |
|---|
| Total participants, beginning-of-year | 2021-06-01 | 682 |
| Total number of active participants reported on line 7a of the Form 5500 | 2021-06-01 | 711 |
| Number of retired or separated participants receiving benefits | 2021-06-01 | 1 |
| Number of other retired or separated participants entitled to future benefits | 2021-06-01 | 35 |
| Total of all active and inactive participants | 2021-06-01 | 747 |
| Number of employers contributing to the scheme | 2021-06-01 | 0 |
| 2020: DECORE-ATIVE SPECIALTIES, INC. GROUP LIFE AND HEALTH INSURANCE PLAN 2020 401k membership |
|---|
| Total participants, beginning-of-year | 2020-06-01 | 823 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-06-01 | 682 |
| Number of retired or separated participants receiving benefits | 2020-06-01 | 1 |
| Number of other retired or separated participants entitled to future benefits | 2020-06-01 | 10 |
| Total of all active and inactive participants | 2020-06-01 | 693 |
| Number of employers contributing to the scheme | 2020-06-01 | 0 |
| 2019: DECORE-ATIVE SPECIALTIES, INC. GROUP LIFE AND HEALTH INSURANCE PLAN 2019 401k membership |
|---|
| Total participants, beginning-of-year | 2019-06-01 | 835 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-06-01 | 823 |
| Number of retired or separated participants receiving benefits | 2019-06-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2019-06-01 | 9 |
| Total of all active and inactive participants | 2019-06-01 | 832 |
| Number of employers contributing to the scheme | 2019-06-01 | 0 |
| 2018: DECORE-ATIVE SPECIALTIES, INC. GROUP LIFE AND HEALTH INSURANCE PLAN 2018 401k membership |
|---|
| Total participants, beginning-of-year | 2018-06-01 | 791 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-06-01 | 835 |
| Number of retired or separated participants receiving benefits | 2018-06-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2018-06-01 | 0 |
| Total of all active and inactive participants | 2018-06-01 | 835 |
| Number of employers contributing to the scheme | 2018-06-01 | 0 |
| 2017: DECORE-ATIVE SPECIALTIES, INC. GROUP LIFE AND HEALTH INSURANCE PLAN 2017 401k membership |
|---|
| Total participants, beginning-of-year | 2017-06-01 | 834 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-06-01 | 791 |
| Number of retired or separated participants receiving benefits | 2017-06-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2017-06-01 | 0 |
| Total of all active and inactive participants | 2017-06-01 | 791 |
| Number of employers contributing to the scheme | 2017-06-01 | 0 |
| 2016: DECORE-ATIVE SPECIALTIES, INC. GROUP LIFE AND HEALTH INSURANCE PLAN 2016 401k membership |
|---|
| Total participants, beginning-of-year | 2016-06-01 | 790 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-06-01 | 804 |
| Number of retired or separated participants receiving benefits | 2016-06-01 | 3 |
| Number of other retired or separated participants entitled to future benefits | 2016-06-01 | 27 |
| Total of all active and inactive participants | 2016-06-01 | 834 |
| Number of employers contributing to the scheme | 2016-06-01 | 0 |
| 2015: DECORE-ATIVE SPECIALTIES, INC. GROUP LIFE AND HEALTH INSURANCE PLAN 2015 401k membership |
|---|
| Total participants, beginning-of-year | 2015-06-01 | 479 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-06-01 | 568 |
| Number of retired or separated participants receiving benefits | 2015-06-01 | 1 |
| Number of other retired or separated participants entitled to future benefits | 2015-06-01 | 0 |
| Total of all active and inactive participants | 2015-06-01 | 569 |
| 2014: DECORE-ATIVE SPECIALTIES, INC. GROUP LIFE AND HEALTH INSURANCE PLAN 2014 401k membership |
|---|
| Total participants, beginning-of-year | 2014-06-01 | 469 |
| Total of all active and inactive participants | 2014-06-01 | 0 |
| Total participants | 2014-06-01 | 0 |
| 2013: DECORE-ATIVE SPECIALTIES, INC. GROUP LIFE AND HEALTH INSURANCE PLAN 2013 401k membership |
|---|
| Total participants, beginning-of-year | 2013-06-01 | 442 |
| Total number of active participants reported on line 7a of the Form 5500 | 2013-06-01 | 469 |
| Number of retired or separated participants receiving benefits | 2013-06-01 | 1 |
| Number of other retired or separated participants entitled to future benefits | 2013-06-01 | 0 |
| Total of all active and inactive participants | 2013-06-01 | 470 |
| 2012: DECORE-ATIVE SPECIALTIES, INC. GROUP LIFE AND HEALTH INSURANCE PLAN 2012 401k membership |
|---|
| Total participants, beginning-of-year | 2012-12-01 | 452 |
| Total number of active participants reported on line 7a of the Form 5500 | 2012-12-01 | 439 |
| Number of retired or separated participants receiving benefits | 2012-12-01 | 3 |
| Number of other retired or separated participants entitled to future benefits | 2012-12-01 | 0 |
| Total of all active and inactive participants | 2012-12-01 | 442 |
| 2011: DECORE-ATIVE SPECIALTIES, INC. GROUP LIFE AND HEALTH INSURANCE PLAN 2011 401k membership |
|---|
| Total participants, beginning-of-year | 2011-12-01 | 651 |
| Total number of active participants reported on line 7a of the Form 5500 | 2011-12-01 | 452 |
| Number of retired or separated participants receiving benefits | 2011-12-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2011-12-01 | 0 |
| Total of all active and inactive participants | 2011-12-01 | 452 |
| 2010: DECORE-ATIVE SPECIALTIES, INC. GROUP LIFE AND HEALTH INSURANCE PLAN 2010 401k membership |
|---|
| Total participants, beginning-of-year | 2010-12-01 | 669 |
| Total number of active participants reported on line 7a of the Form 5500 | 2010-12-01 | 634 |
| Number of retired or separated participants receiving benefits | 2010-12-01 | 17 |
| Number of other retired or separated participants entitled to future benefits | 2010-12-01 | 0 |
| Total of all active and inactive participants | 2010-12-01 | 651 |
| 2009: DECORE-ATIVE SPECIALTIES, INC. GROUP LIFE AND HEALTH INSURANCE PLAN 2009 401k membership |
|---|
| Total participants, beginning-of-year | 2009-12-01 | 761 |
| Total number of active participants reported on line 7a of the Form 5500 | 2009-12-01 | 642 |
| Number of retired or separated participants receiving benefits | 2009-12-01 | 9 |
| Number of other retired or separated participants entitled to future benefits | 2009-12-01 | 18 |
| Total of all active and inactive participants | 2009-12-01 | 669 |
| 2022: DECORE-ATIVE SPECIALTIES, INC. GROUP LIFE AND HEALTH INSURANCE PLAN 2022 form 5500 responses |
|---|
| 2022-06-01 | Type of plan entity | Single employer plan |
| 2022-06-01 | Plan funding arrangement – Insurance | Yes |
| 2022-06-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2022-06-01 | Plan benefit arrangement – Insurance | Yes |
| 2022-06-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2021: DECORE-ATIVE SPECIALTIES, INC. GROUP LIFE AND HEALTH INSURANCE PLAN 2021 form 5500 responses |
|---|
| 2021-06-01 | Type of plan entity | Single employer plan |
| 2021-06-01 | Plan funding arrangement – Insurance | Yes |
| 2021-06-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2021-06-01 | Plan benefit arrangement – Insurance | Yes |
| 2021-06-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2020: DECORE-ATIVE SPECIALTIES, INC. GROUP LIFE AND HEALTH INSURANCE PLAN 2020 form 5500 responses |
|---|
| 2020-06-01 | Type of plan entity | Single employer plan |
| 2020-06-01 | Plan funding arrangement – Insurance | Yes |
| 2020-06-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2020-06-01 | Plan benefit arrangement – Insurance | Yes |
| 2020-06-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2019: DECORE-ATIVE SPECIALTIES, INC. GROUP LIFE AND HEALTH INSURANCE PLAN 2019 form 5500 responses |
|---|
| 2019-06-01 | Type of plan entity | Single employer plan |
| 2019-06-01 | Plan funding arrangement – Insurance | Yes |
| 2019-06-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2019-06-01 | Plan benefit arrangement – Insurance | Yes |
| 2019-06-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2018: DECORE-ATIVE SPECIALTIES, INC. GROUP LIFE AND HEALTH INSURANCE PLAN 2018 form 5500 responses |
|---|
| 2018-06-01 | Type of plan entity | Single employer plan |
| 2018-06-01 | Plan funding arrangement – Insurance | Yes |
| 2018-06-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2018-06-01 | Plan benefit arrangement – Insurance | Yes |
| 2018-06-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2017: DECORE-ATIVE SPECIALTIES, INC. GROUP LIFE AND HEALTH INSURANCE PLAN 2017 form 5500 responses |
|---|
| 2017-06-01 | Type of plan entity | Single employer plan |
| 2017-06-01 | Submission has been amended | Yes |
| 2017-06-01 | Plan funding arrangement – Insurance | Yes |
| 2017-06-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2017-06-01 | Plan benefit arrangement – Insurance | Yes |
| 2017-06-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2016: DECORE-ATIVE SPECIALTIES, INC. GROUP LIFE AND HEALTH INSURANCE PLAN 2016 form 5500 responses |
|---|
| 2016-06-01 | Type of plan entity | Single employer plan |
| 2016-06-01 | Submission has been amended | No |
| 2016-06-01 | This submission is the final filing | No |
| 2016-06-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2016-06-01 | Plan is a collectively bargained plan | No |
| 2016-06-01 | Plan funding arrangement – Insurance | Yes |
| 2016-06-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2016-06-01 | Plan benefit arrangement – Insurance | Yes |
| 2016-06-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2015: DECORE-ATIVE SPECIALTIES, INC. GROUP LIFE AND HEALTH INSURANCE PLAN 2015 form 5500 responses |
|---|
| 2015-06-01 | Type of plan entity | Single employer plan |
| 2015-06-01 | Submission has been amended | No |
| 2015-06-01 | This submission is the final filing | No |
| 2015-06-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2015-06-01 | Plan is a collectively bargained plan | No |
| 2015-06-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2015-06-01 | Plan benefit arrangement – Insurance | Yes |
| 2015-06-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2014: DECORE-ATIVE SPECIALTIES, INC. GROUP LIFE AND HEALTH INSURANCE PLAN 2014 form 5500 responses |
|---|
| 2014-06-01 | Type of plan entity | Single employer plan |
| 2014-06-01 | Submission has been amended | No |
| 2014-06-01 | This submission is the final filing | No |
| 2014-06-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2014-06-01 | Plan is a collectively bargained plan | No |
| 2014-06-01 | Plan funding arrangement – Insurance | Yes |
| 2014-06-01 | Plan benefit arrangement – Insurance | Yes |
| 2013: DECORE-ATIVE SPECIALTIES, INC. GROUP LIFE AND HEALTH INSURANCE PLAN 2013 form 5500 responses |
|---|
| 2013-06-01 | Type of plan entity | Single employer plan |
| 2013-06-01 | Submission has been amended | No |
| 2013-06-01 | This submission is the final filing | No |
| 2013-06-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2013-06-01 | Plan is a collectively bargained plan | No |
| 2013-06-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2013-06-01 | Plan benefit arrangement – Insurance | Yes |
| 2013-06-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2012: DECORE-ATIVE SPECIALTIES, INC. GROUP LIFE AND HEALTH INSURANCE PLAN 2012 form 5500 responses |
|---|
| 2012-12-01 | Type of plan entity | Single employer plan |
| 2012-12-01 | Submission has been amended | No |
| 2012-12-01 | This submission is the final filing | No |
| 2012-12-01 | This return/report is a short plan year return/report (less than 12 months) | Yes |
| 2012-12-01 | Plan is a collectively bargained plan | No |
| 2012-12-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2012-12-01 | Plan benefit arrangement – Insurance | Yes |
| 2011: DECORE-ATIVE SPECIALTIES, INC. GROUP LIFE AND HEALTH INSURANCE PLAN 2011 form 5500 responses |
|---|
| 2011-12-01 | Type of plan entity | Single employer plan |
| 2011-12-01 | Submission has been amended | No |
| 2011-12-01 | This submission is the final filing | No |
| 2011-12-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2011-12-01 | Plan is a collectively bargained plan | No |
| 2011-12-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2011-12-01 | Plan benefit arrangement – Insurance | Yes |
| 2010: DECORE-ATIVE SPECIALTIES, INC. GROUP LIFE AND HEALTH INSURANCE PLAN 2010 form 5500 responses |
|---|
| 2010-12-01 | Type of plan entity | Single employer plan |
| 2010-12-01 | Submission has been amended | No |
| 2010-12-01 | This submission is the final filing | No |
| 2010-12-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2010-12-01 | Plan is a collectively bargained plan | No |
| 2010-12-01 | Plan funding arrangement – Insurance | Yes |
| 2010-12-01 | Plan benefit arrangement – Insurance | Yes |
| 2009: DECORE-ATIVE SPECIALTIES, INC. GROUP LIFE AND HEALTH INSURANCE PLAN 2009 form 5500 responses |
|---|
| 2009-12-01 | Type of plan entity | Single employer plan |
| 2009-12-01 | Submission has been amended | No |
| 2009-12-01 | This submission is the final filing | No |
| 2009-12-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2009-12-01 | Plan is a collectively bargained plan | No |
| 2009-12-01 | Plan funding arrangement – Insurance | Yes |
| 2009-12-01 | Plan benefit arrangement – Insurance | Yes |
| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
| Policy contract number | 165134 |
| Policy instance | 5 |
| Insurance contract or identification number | 165134 | | Number of Individuals Covered | 448 | | Insurance policy start date | 2022-06-01 | | Insurance policy end date | 2023-05-31 | | Total amount of commissions paid to insurance broker | USD $22,000 | | Total amount of fees paid to insurance company | USD $3,476 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $237,796 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $22,000 | | Amount paid for insurance broker fees | 3465 | | Additional information about fees paid to insurance broker | SUPPLEMENTAL COMPENSATION, NON-MONETARY COMPENSATION | | Insurance broker organization code? | 3 |
|
| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
| Policy contract number | 803614G |
| Policy instance | 4 |
| Insurance contract or identification number | 803614G | | Number of Individuals Covered | 779 | | Insurance policy start date | 2022-06-01 | | Insurance policy end date | 2023-05-31 | | Total amount of commissions paid to insurance broker | USD $24,380 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT, EMPLOYEE ASSISTANCE PROGRAM | | Welfare Benefit Premiums Paid to Carrier | USD $265,210 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $24,380 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 479110 |
| Policy instance | 3 |
| Insurance contract or identification number | 479110 | | Number of Individuals Covered | 4 | | Insurance policy start date | 2022-06-01 | | Insurance policy end date | 2023-05-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $10,683 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| SAFEGUARD HEALTH PLANS, INC. A CALIFORNIA CORPORATION (National Association of Insurance Commissioners NAIC id number: 96030 ) |
| Policy contract number | 165134 |
| Policy instance | 2 |
| Insurance contract or identification number | 165134 | | Number of Individuals Covered | 139 | | Insurance policy start date | 2022-06-01 | | Insurance policy end date | 2023-05-31 | | Total amount of commissions paid to insurance broker | USD $2,105 | | Total amount of fees paid to insurance company | USD $324 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $22,315 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,105 | | Amount paid for insurance broker fees | 324 | | Additional information about fees paid to insurance broker | SUPPLEMENTAL COMPENSATION | | Insurance broker organization code? | 3 |
|
| ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 ) |
| Policy contract number | 278581 |
| Policy instance | 1 |
| Insurance contract or identification number | 278581 | | Number of Individuals Covered | 562 | | Insurance policy start date | 2022-06-01 | | Insurance policy end date | 2023-05-31 | | Total amount of commissions paid to insurance broker | USD $3,146 | | Total amount of fees paid to insurance company | USD $294 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $29,594 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,146 | | Amount paid for insurance broker fees | 294 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker organization code? | 3 |
|
| PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 ) |
| Policy contract number | 163034 |
| Policy instance | 6 |
| Insurance contract or identification number | 163034 | | Number of Individuals Covered | 24 | | Insurance policy start date | 2022-06-01 | | Insurance policy end date | 2023-05-31 | | Total amount of commissions paid to insurance broker | USD $4,161 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Welfare Benefit Premiums Paid to Carrier | USD $50,365 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,216 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
| Policy contract number | 165134 |
| Policy instance | 5 |
| Insurance contract or identification number | 165134 | | Number of Individuals Covered | 427 | | Insurance policy start date | 2021-06-01 | | Insurance policy end date | 2022-05-31 | | Total amount of commissions paid to insurance broker | USD $27,411 | | Total amount of fees paid to insurance company | USD $5,530 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $262,211 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $27,411 | | Amount paid for insurance broker fees | 5530 | | Additional information about fees paid to insurance broker | SUPPLEMENTAL COMPENSATION, NON-MONETARY COMPENSATION | | Insurance broker organization code? | 3 |
|
| SAFEGUARD HEALTH PLANS, INC. A CALIFORNIA CORPORATION (National Association of Insurance Commissioners NAIC id number: 96030 ) |
| Policy contract number | 165134 |
| Policy instance | 2 |
| Insurance contract or identification number | 165134 | | Number of Individuals Covered | 171 | | Insurance policy start date | 2021-06-01 | | Insurance policy end date | 2022-05-31 | | Total amount of commissions paid to insurance broker | USD $2,521 | | Total amount of fees paid to insurance company | USD $509 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $24,563 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,521 | | Amount paid for insurance broker fees | 509 | | Additional information about fees paid to insurance broker | SUPPLEMENTAL COMPENSATION | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 479110 |
| Policy instance | 3 |
| Insurance contract or identification number | 479110 | | Number of Individuals Covered | 4 | | Insurance policy start date | 2021-06-01 | | Insurance policy end date | 2022-05-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $13,083 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
| Policy contract number | 803614G |
| Policy instance | 4 |
| Insurance contract or identification number | 803614G | | Number of Individuals Covered | 711 | | Insurance policy start date | 2021-06-01 | | Insurance policy end date | 2022-05-31 | | Total amount of commissions paid to insurance broker | USD $25,698 | | Total amount of fees paid to insurance company | USD $8,347 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT, EMPLOYEE ASSISTANCE PROGRAM | | Welfare Benefit Premiums Paid to Carrier | USD $235,570 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $25,698 | | Amount paid for insurance broker fees | 8347 | | Additional information about fees paid to insurance broker | BONUS | | Insurance broker organization code? | 3 |
|
| PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 ) |
| Policy contract number | 163034 |
| Policy instance | 6 |
| Insurance contract or identification number | 163034 | | Number of Individuals Covered | 25 | | Insurance policy start date | 2021-06-01 | | Insurance policy end date | 2022-05-31 | | Total amount of commissions paid to insurance broker | USD $2,722 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Welfare Benefit Premiums Paid to Carrier | USD $48,572 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,392 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 ) |
| Policy contract number | 278581 |
| Policy instance | 1 |
| Insurance contract or identification number | 278581 | | Number of Individuals Covered | 650 | | Insurance policy start date | 2021-06-01 | | Insurance policy end date | 2022-05-31 | | Total amount of commissions paid to insurance broker | USD $3,444 | | Total amount of fees paid to insurance company | USD $334 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $39,297 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,444 | | Amount paid for insurance broker fees | 334 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker organization code? | 3 |
|
| ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 ) |
| Policy contract number | 278581 |
| Policy instance | 1 |
| Insurance contract or identification number | 278581 | | Number of Individuals Covered | 738 | | Insurance policy start date | 2020-06-01 | | Insurance policy end date | 2021-05-31 | | Total amount of commissions paid to insurance broker | USD $3,942 | | Total amount of fees paid to insurance company | USD $360 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $46,118 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,942 | | Amount paid for insurance broker fees | 360 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker organization code? | 3 |
|
| SAFEGUARD HEALTH PLANS, INC. A CALIFORNIA CORPORATION (National Association of Insurance Commissioners NAIC id number: 96030 ) |
| Policy contract number | 165134 |
| Policy instance | 2 |
| Insurance contract or identification number | 165134 | | Number of Individuals Covered | 212 | | Insurance policy start date | 2020-06-01 | | Insurance policy end date | 2021-05-31 | | Total amount of commissions paid to insurance broker | USD $3,109 | | Total amount of fees paid to insurance company | USD $407 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $29,972 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,109 | | Amount paid for insurance broker fees | 206 | | Additional information about fees paid to insurance broker | SUPPLEMENTAL COMPENSATION | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 479110 |
| Policy instance | 3 |
| Insurance contract or identification number | 479110 | | Number of Individuals Covered | 4 | | Insurance policy start date | 2020-06-01 | | Insurance policy end date | 2021-05-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $11,356 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
| Policy contract number | 803614G |
| Policy instance | 4 |
| Insurance contract or identification number | 803614G | | Number of Individuals Covered | 682 | | Insurance policy start date | 2020-06-01 | | Insurance policy end date | 2021-05-31 | | Total amount of commissions paid to insurance broker | USD $24,107 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $241,065 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $24,107 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
| Policy contract number | 165134 |
| Policy instance | 5 |
| Insurance contract or identification number | 165134 | | Number of Individuals Covered | 588 | | Insurance policy start date | 2020-06-01 | | Insurance policy end date | 2021-05-31 | | Total amount of commissions paid to insurance broker | USD $27,316 | | Total amount of fees paid to insurance company | USD $3,602 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $273,947 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $27,316 | | Amount paid for insurance broker fees | 1949 | | Additional information about fees paid to insurance broker | SUPPLEMENTAL COMPENSATION NON-MONETARY COMPENSATION | | Insurance broker organization code? | 3 |
|
| PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 ) |
| Policy contract number | 163034 |
| Policy instance | 6 |
| Insurance contract or identification number | 163034 | | Number of Individuals Covered | 28 | | Insurance policy start date | 2020-06-01 | | Insurance policy end date | 2021-05-31 | | Total amount of commissions paid to insurance broker | USD $3,298 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Welfare Benefit Premiums Paid to Carrier | USD $50,394 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,885 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 ) |
| Policy contract number | 163034 |
| Policy instance | 6 |
| Insurance contract or identification number | 163034 | | Number of Individuals Covered | 20 | | Insurance policy start date | 2019-06-01 | | Insurance policy end date | 2020-05-31 | | Total amount of commissions paid to insurance broker | USD $2,537 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Welfare Benefit Premiums Paid to Carrier | USD $39,308 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,097 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
| Policy contract number | 165134 |
| Policy instance | 5 |
| Insurance contract or identification number | 165134 | | Number of Individuals Covered | 642 | | Insurance policy start date | 2019-06-01 | | Insurance policy end date | 2020-05-31 | | Total amount of commissions paid to insurance broker | USD $32,105 | | Total amount of fees paid to insurance company | USD $4,852 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $324,912 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $32,105 | | Amount paid for insurance broker fees | 41 | | Additional information about fees paid to insurance broker | NON-MONETARY COMPENSATION | | Insurance broker organization code? | 3 |
|
| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
| Policy contract number | 803614G |
| Policy instance | 4 |
| Insurance contract or identification number | 803614G | | Number of Individuals Covered | 841 | | Insurance policy start date | 2019-06-01 | | Insurance policy end date | 2020-05-31 | | Total amount of commissions paid to insurance broker | USD $19,318 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $193,178 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $19,318 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 479110 |
| Policy instance | 3 |
| Insurance contract or identification number | 479110 | | Number of Individuals Covered | 4 | | Insurance policy start date | 2019-06-01 | | Insurance policy end date | 2020-05-31 | | Total amount of commissions paid to insurance broker | USD $56 | | Total amount of fees paid to insurance company | USD $0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $12,389 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $56 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| SAFEGUARD HEALTH PLANS, INC. A CALIFORNIA CORPORATION (National Association of Insurance Commissioners NAIC id number: 96030 ) |
| Policy contract number | 165134 |
| Policy instance | 2 |
| Insurance contract or identification number | 165134 | | Number of Individuals Covered | 284 | | Insurance policy start date | 2019-06-01 | | Insurance policy end date | 2020-05-31 | | Total amount of commissions paid to insurance broker | USD $3,999 | | Total amount of fees paid to insurance company | USD $605 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $40,509 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,999 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Additional information about fees paid to insurance broker | SUPPLEMENTAL COMPENSATION |
|
| ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 ) |
| Policy contract number | 278581 |
| Policy instance | 1 |
| Insurance contract or identification number | 278581 | | Number of Individuals Covered | 820 | | Insurance policy start date | 2019-06-01 | | Insurance policy end date | 2020-05-31 | | Total amount of commissions paid to insurance broker | USD $3,775 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $56,472 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,773 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 ) |
| Policy contract number | 278581 |
| Policy instance | 1 |
| Insurance contract or identification number | 278581 | | Number of Individuals Covered | 840 | | Insurance policy start date | 2018-06-01 | | Insurance policy end date | 2019-05-31 | | Total amount of commissions paid to insurance broker | USD $3,692 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $49,823 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,029 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| SAFEGUARD HEALTH PLANS, INC. A CALIFORNIA CORPORATION (National Association of Insurance Commissioners NAIC id number: 96030 ) |
| Policy contract number | 165134 |
| Policy instance | 2 |
| Insurance contract or identification number | 165134 | | Number of Individuals Covered | 297 | | Insurance policy start date | 2018-06-01 | | Insurance policy end date | 2019-05-31 | | Total amount of commissions paid to insurance broker | USD $4,822 | | Total amount of fees paid to insurance company | USD $603 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $44,201 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,822 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Additional information about fees paid to insurance broker | SUPPLEMENTAL COMPENSATION |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 479110 |
| Policy instance | 3 |
| Insurance contract or identification number | 479110 | | Number of Individuals Covered | 6 | | Insurance policy start date | 2018-06-01 | | Insurance policy end date | 2019-05-31 | | Total amount of commissions paid to insurance broker | USD $413 | | Total amount of fees paid to insurance company | USD $0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $14,444 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $413 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 473374 |
| Policy instance | 4 |
| Insurance contract or identification number | 473374 | | Number of Individuals Covered | 835 | | Insurance policy start date | 2018-06-01 | | Insurance policy end date | 2019-05-31 | | Total amount of commissions paid to insurance broker | USD $22,210 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $205,601 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $22,210 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 ) |
| Policy contract number | 145710 |
| Policy instance | 6 |
| Insurance contract or identification number | 145710 | | Number of Individuals Covered | 22 | | Insurance policy start date | 2018-06-01 | | Insurance policy end date | 2019-05-31 | | Total amount of commissions paid to insurance broker | USD $3,018 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Welfare Benefit Premiums Paid to Carrier | USD $48,809 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $620 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
| Policy contract number | 165134 |
| Policy instance | 5 |
| Insurance contract or identification number | 165134 | | Number of Individuals Covered | 660 | | Insurance policy start date | 2018-06-01 | | Insurance policy end date | 2019-05-31 | | Total amount of commissions paid to insurance broker | USD $31,649 | | Total amount of fees paid to insurance company | USD $4,016 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $298,198 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $31,649 | | Amount paid for insurance broker fees | 60 | | Additional information about fees paid to insurance broker | NON-MONETARY COMPENSATION | | Insurance broker organization code? | 3 |
|
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 473374 |
| Policy instance | 3 |
| Insurance contract or identification number | 473374 | | Number of Individuals Covered | 806 | | Insurance policy start date | 2017-06-01 | | Insurance policy end date | 2018-05-31 | | Total amount of commissions paid to insurance broker | USD $16,399 | | Total amount of fees paid to insurance company | USD $71 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $179,927 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
| Policy contract number | 165134 |
| Policy instance | 4 |
| Insurance contract or identification number | 165134 | | Number of Individuals Covered | 589 | | Insurance policy start date | 2017-06-01 | | Insurance policy end date | 2018-05-31 | | Total amount of commissions paid to insurance broker | USD $48,218 | | Total amount of fees paid to insurance company | USD $6,787 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $264,911 | | 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 number | 479110 |
| Policy instance | 5 |
| Insurance contract or identification number | 479110 | | Number of Individuals Covered | 8 | | Insurance policy start date | 2017-06-01 | | Insurance policy end date | 2018-05-31 | | Total amount of commissions paid to insurance broker | USD $635 | | Total amount of fees paid to insurance company | USD $0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $18,654 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 ) |
| Policy contract number | 163034 |
| Policy instance | 6 |
| Insurance contract or identification number | 163034 | | Number of Individuals Covered | 24 | | Insurance policy start date | 2017-06-01 | | Insurance policy end date | 2018-05-31 | | Total amount of commissions paid to insurance broker | USD $6,935 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Welfare Benefit Premiums Paid to Carrier | USD $48,575 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
| Policy contract number | 165134 |
| Policy instance | 5 |
| Insurance contract or identification number | 165134 | | Number of Individuals Covered | 589 | | Insurance policy start date | 2017-06-01 | | Insurance policy end date | 2018-05-31 | | Total amount of commissions paid to insurance broker | USD $48,218 | | Total amount of fees paid to insurance company | USD $6,787 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $264,911 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $28,629 | | Amount paid for insurance broker fees | 51 | | Additional information about fees paid to insurance broker | NON-MONETARY COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | USI INSURANCE SERVICES, LLC |
|
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 473374 |
| Policy instance | 4 |
| Insurance contract or identification number | 473374 | | Number of Individuals Covered | 806 | | Insurance policy start date | 2017-06-01 | | Insurance policy end date | 2018-05-31 | | Total amount of commissions paid to insurance broker | USD $16,399 | | Total amount of fees paid to insurance company | USD $71 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $179,927 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $9,828 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Additional information about fees paid to insurance broker | INDIRECT COMPENSATION | | Insurance broker name | WILLIS INSURANCE SERVICES |
|
| PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 ) |
| Policy contract number | 163034 |
| Policy instance | 3 |
| Insurance contract or identification number | 163034 | | Number of Individuals Covered | 11 | | Insurance policy start date | 2016-10-01 | | Insurance policy end date | 2017-09-30 | | Total amount of commissions paid to insurance broker | USD $5,878 | | Total amount of fees paid to insurance company | USD $635 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $12,144 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,878 | | Amount paid for insurance broker fees | 635 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | WILLIS INSURANCE SERVICES |
|
| SAFEGUARD HEALTH PLANS, INC. A CALIFORNIA CORPORATION (National Association of Insurance Commissioners NAIC id number: 96030 ) |
| Policy contract number | 165134 |
| Policy instance | 2 |
| Insurance contract or identification number | 165134 | | Number of Individuals Covered | 329 | | Insurance policy start date | 2017-06-01 | | Insurance policy end date | 2018-05-31 | | Total amount of commissions paid to insurance broker | USD $9,023 | | Total amount of fees paid to insurance company | USD $1,171 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $42,961 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,405 | | Amount paid for insurance broker fees | 523 | | Additional information about fees paid to insurance broker | SUPPLEMENTAL COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | USI INSURANCE SERVICES, LLC |
|
| ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 ) |
| Policy contract number | 278581 |
| Policy instance | 1 |
| Insurance contract or identification number | 278581 | | Number of Individuals Covered | 855 | | Insurance policy start date | 2017-06-01 | | Insurance policy end date | 2018-05-31 | | Total amount of commissions paid to insurance broker | USD $3,895 | | Total amount of fees paid to insurance company | USD $603 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $51,991 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,276 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | WELLS FARGO INSURANCE |
|
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 473374 |
| Policy instance | 1 |
| Insurance contract or identification number | 473374 | | Number of Individuals Covered | 766 | | Insurance policy start date | 2015-06-01 | | Insurance policy end date | 2016-05-31 | | Total amount of commissions paid to insurance broker | USD $17,735 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH & 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 Carrier | USD $176,406 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $14,698 | | Insurance broker organization code? | 3 | | Insurance broker name | WILLIS |
|
| PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 ) |
| Policy contract number | 145710 |
| Policy instance | 2 |
| Insurance contract or identification number | 145710 | | Number of Individuals Covered | 29 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $1,846 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $21,100 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,358 | | Insurance broker organization code? | 3 | | Insurance broker name | USI INSURANCE SERVICES LLC |
|
| ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 ) |
| Policy contract number | 278581 |
| Policy instance | 3 |
| Insurance contract or identification number | 278581 | | Number of Individuals Covered | 291 | | Insurance policy start date | 2015-06-01 | | Insurance policy end date | 2016-05-31 | | Total amount of commissions paid to insurance broker | USD $1,197 | | Total amount of fees paid to insurance company | USD $32 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $38,084 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $995 | | Amount paid for insurance broker fees | 32 | | Additional information about fees paid to insurance broker | BROKER FEES | | Insurance broker organization code? | 3 | | Insurance broker name | WILLIS |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 479110 |
| Policy instance | 5 |
| Insurance contract or identification number | 479110 | | Number of Individuals Covered | 9 | | Insurance policy start date | 2015-06-01 | | Insurance policy end date | 2016-05-31 | | Total amount of commissions paid to insurance broker | USD $940 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $22,818 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $940 | | Insurance broker organization code? | 3 | | Insurance broker name | DODGE WARREN & PETERS INS. SVCS. |
|
| BLUECROSS BLUESHIELD OF NORTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 54631 ) |
| Policy contract number | 080397 |
| Policy instance | 6 |
| Insurance contract or identification number | 080397 | | Number of Individuals Covered | 163 | | Insurance policy start date | 2015-06-01 | | Insurance policy end date | 2016-05-31 | | Total amount of commissions paid to insurance broker | USD $72,190 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $1,676,010 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $72,190 | | Insurance broker organization code? | 3 | | Insurance broker name | PAUL M GROH |
|
| BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 278581 |
| Policy instance | 4 |
| Insurance contract or identification number | 278581 | | Number of Individuals Covered | 405 | | Insurance policy start date | 2015-06-01 | | Insurance policy end date | 2016-05-31 | | Total amount of commissions paid to insurance broker | USD $124,404 | | Total amount of fees paid to insurance company | USD $3,328 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $3,960,189 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $103,432 | | Amount paid for insurance broker fees | 3328 | | Additional information about fees paid to insurance broker | BROKER FEES | | Insurance broker organization code? | 3 | | Insurance broker name | WILLIS |
|
| BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 278581 |
| Policy instance | 4 |
| Insurance contract or identification number | 278581 | | Number of Individuals Covered | 906 | | Insurance policy start date | 2014-06-01 | | Insurance policy end date | 2015-05-31 | | Total amount of commissions paid to insurance broker | USD $107,446 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $3,769,683 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $107,446 | | Insurance broker organization code? | 3 | | Insurance broker name | JAMES G PARKER INSURANCE ASSOCIATES |
|
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 0473374 |
| Policy instance | 3 |
| Insurance contract or identification number | 0473374 | | Number of Individuals Covered | 751 | | Insurance policy start date | 2014-06-01 | | Insurance policy end date | 2015-05-31 | | Total amount of commissions paid to insurance broker | USD $16,217 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | AD&D | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $163,097 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $16,217 | | Insurance broker organization code? | 3 | | Insurance broker name | JAMES G PARKER INSURANCE ASSOCIATES |
|
| ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 ) |
| Policy contract number | 152257 |
| Policy instance | 2 |
| Insurance contract or identification number | 152257 | | Number of Individuals Covered | 241 | | Insurance policy start date | 2014-06-01 | | Insurance policy end date | 2015-05-31 | | Total amount of commissions paid to insurance broker | USD $23,055 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $230,546 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $23,055 | | Insurance broker organization code? | 3 | | Insurance broker name | JAMES G PARKER INSURANCE ASSOCIATES |
|
| BLUECROSS BLUESHIELD OF NORTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 54631 ) |
| Policy contract number | 080397 |
| Policy instance | 1 |
| Insurance contract or identification number | 080397 | | Number of Individuals Covered | 477 | | Insurance policy start date | 2014-06-01 | | Insurance policy end date | 2015-05-31 | | Total amount of commissions paid to insurance broker | USD $39,292 | | Total amount of fees paid to insurance company | USD $3,000 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $39,292 | | Amount paid for insurance broker fees | 3000 | | Additional information about fees paid to insurance broker | ADMINISTRATIVE | | Insurance broker organization code? | 3 | | Insurance broker name | JAMES G PARKER INSURANCE ASSOCIATES |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 479110 |
| Policy instance | 5 |
| Insurance contract or identification number | 479110 | | Number of Individuals Covered | 10 | | Insurance policy start date | 2014-06-01 | | Insurance policy end date | 2015-05-31 | | Total amount of commissions paid to insurance broker | USD $875 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $24,871 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $875 | | Insurance broker organization code? | 3 | | Insurance broker name | DODGE WARREN & PETERS INS SERVICES |
|
| BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 ) |
| Policy contract number | MLP0390 |
| Policy instance | 4 |
| Insurance contract or identification number | MLP0390 | | Number of Individuals Covered | 80 | | Insurance policy start date | 2012-12-01 | | Insurance policy end date | 2013-11-30 | | Total amount of commissions paid to insurance broker | USD $1,787 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $45,990 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,403 | | Insurance broker organization code? | 3 | | Insurance broker name | EDGEWOOD PARTNERS INSURANCE CENTER |
|
| CIGNA HEALTHCARE OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: N/A ) |
| Policy contract number | 3335890 |
| Policy instance | 3 |
| Insurance contract or identification number | 3335890 | | Number of Individuals Covered | 940 | | Insurance policy start date | 2013-06-01 | | Insurance policy end date | 2014-05-31 | | Total amount of commissions paid to insurance broker | USD $81,715 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $81,715 | | Insurance broker organization code? | 3 | | Insurance broker name | JAMES G. PARKER INSURANCE |
|
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 473374 |
| Policy instance | 2 |
| Insurance contract or identification number | 473374 | | Number of Individuals Covered | 739 | | Insurance policy start date | 2013-06-01 | | Insurance policy end date | 2014-05-31 | | Total amount of commissions paid to insurance broker | USD $15,227 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH & 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 Carrier | USD $152,699 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $15,227 | | Insurance broker organization code? | 3 | | Insurance broker name | JAMES G. PARKER INSURANCE |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 479110 |
| Policy instance | 1 |
| Insurance contract or identification number | 479110 | | Number of Individuals Covered | 10 | | Insurance policy start date | 2013-06-01 | | Insurance policy end date | 2014-05-31 | | Total amount of commissions paid to insurance broker | USD $900 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | DISABILITY | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $24,009 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $900 | | Insurance broker organization code? | 3 | | Insurance broker name | DODGE WARREN & PETERS |
|
| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
| Policy contract number | 3335890 |
| Policy instance | 5 |
| Insurance contract or identification number | 3335890 | | Number of Individuals Covered | 1275 | | Insurance policy start date | 2013-06-01 | | Insurance policy end date | 2014-05-31 | | Total amount of commissions paid to insurance broker | USD $82,909 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $943,691 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $82,720 | | Insurance broker organization code? | 3 | | Insurance broker name | EDGEWOOD PARTNERS INSURANCE CENTER |
|
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 473374 |
| Policy instance | 1 |
| Insurance contract or identification number | 473374 | | Number of Individuals Covered | 642 | | Insurance policy start date | 2012-06-01 | | Insurance policy end date | 2013-05-31 | | Total amount of commissions paid to insurance broker | USD $13,254 | | Total amount of fees paid to insurance company | USD $633 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH & 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 Carrier | USD $144,917 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,389 | | Amount paid for insurance broker fees | 633 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | JAMES G. PARKER INSURANCE |
|
| CIGNA HEALTHCARE OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: N/A ) |
| Policy contract number | 3335890 |
| Policy instance | 3 |
| Insurance contract or identification number | 3335890 | | Number of Individuals Covered | 884 | | Insurance policy start date | 2012-06-01 | | Insurance policy end date | 2013-05-31 | | Total amount of commissions paid to insurance broker | USD $70,492 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $42,615 | | Insurance broker organization code? | 3 | | Insurance broker name | JAMES G. PARKER INSURANCE |
|
| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
| Policy contract number | 3335890 |
| Policy instance | 2 |
| Insurance contract or identification number | 3335890 | | Number of Individuals Covered | 1200 | | Insurance policy start date | 2012-06-01 | | Insurance policy end date | 2013-05-31 | | Total amount of commissions paid to insurance broker | USD $71,252 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $866,422 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $42,042 | | Insurance broker organization code? | 3 | | Insurance broker name | JAMES G. PARKER INSURANCE |
|
| BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | C16145 |
| Policy instance | 7 |
| Insurance contract or identification number | C16145 | | Number of Individuals Covered | 0 | | Insurance policy start date | 2011-12-01 | | Insurance policy end date | 2012-05-31 | | Total amount of commissions paid to insurance broker | USD $52,751 | | Total amount of fees paid to insurance company | USD $4,468 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH & 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 Carrier | USD $1,582,378 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUC0488A |
| Policy instance | 1 |
| Insurance contract or identification number | GUC0488A | | Number of Individuals Covered | 39 | | Insurance policy start date | 2011-12-01 | | Insurance policy end date | 2012-05-31 | | Total amount of commissions paid to insurance broker | USD $527 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $5,272 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLTD0488A |
| Policy instance | 2 |
| Insurance contract or identification number | GLTD0488A | | Number of Individuals Covered | 129 | | Insurance policy start date | 2011-10-01 | | Insurance policy end date | 2012-05-31 | | Total amount of commissions paid to insurance broker | USD $1,727 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $17,272 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 ) |
| Policy contract number | 134-1090012 |
| Policy instance | 3 |
| Insurance contract or identification number | 134-1090012 | | Number of Individuals Covered | 69 | | Insurance policy start date | 2011-12-01 | | Insurance policy end date | 2012-05-31 | | Total amount of commissions paid to insurance broker | USD $2,661 | | Total amount of fees paid to insurance company | USD $371 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH & 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 Carrier | USD $17,742 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 704949 |
| Policy instance | 4 |
| Insurance contract or identification number | 704949 | | Number of Individuals Covered | 342 | | Insurance policy start date | 2011-12-01 | | Insurance policy end date | 2012-05-31 | | Total amount of commissions paid to insurance broker | USD $19,099 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $475,719 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 ) |
| Policy contract number | MLP0390 |
| Policy instance | 5 |
| Insurance contract or identification number | MLP0390 | | Number of Individuals Covered | 73 | | Insurance policy start date | 2011-12-01 | | Insurance policy end date | 2012-11-30 | | Total amount of commissions paid to insurance broker | USD $1,426 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $36,556 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GVTL0488A |
| Policy instance | 6 |
| Insurance contract or identification number | GVTL0488A | | Number of Individuals Covered | 152 | | Insurance policy start date | 2011-12-01 | | Insurance policy end date | 2012-05-31 | | Total amount of commissions paid to insurance broker | USD $2,406 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH & 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 Carrier | USD $24,062 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 ) |
| Policy contract number | 134-1090012 |
| Policy instance | 1 |
| Insurance contract or identification number | 134-1090012 | | Number of Individuals Covered | 73 | | Insurance policy start date | 2010-12-01 | | Insurance policy end date | 2011-11-30 | | Total amount of commissions paid to insurance broker | USD $5,947 | | Total amount of fees paid to insurance company | USD $972 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH & 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 Carrier | USD $35,268 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 ) |
| Policy contract number | MLP0390 |
| Policy instance | 3 |
| Insurance contract or identification number | MLP0390 | | Number of Individuals Covered | 56 | | Insurance policy start date | 2010-12-01 | | Insurance policy end date | 2011-11-30 | | Total amount of commissions paid to insurance broker | USD $1,146 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $30,171 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GVTL0488A |
| Policy instance | 4 |
| Insurance contract or identification number | GVTL0488A | | Number of Individuals Covered | 153 | | Insurance policy start date | 2010-12-01 | | Insurance policy end date | 2011-11-30 | | Total amount of commissions paid to insurance broker | USD $5,531 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH & 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 Carrier | USD $45,527 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 704949 |
| Policy instance | 5 |
| Insurance contract or identification number | 704949 | | Number of Individuals Covered | 342 | | Insurance policy start date | 2010-12-01 | | Insurance policy end date | 2011-11-30 | | Total amount of commissions paid to insurance broker | USD $46,413 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $1,074,093 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | C16145 |
| Policy instance | 6 |
| Insurance contract or identification number | C16145 | | Number of Individuals Covered | 370 | | Insurance policy start date | 2010-12-01 | | Insurance policy end date | 2011-11-30 | | Total amount of commissions paid to insurance broker | USD $112,413 | | Total amount of fees paid to insurance company | USD $21,471 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH & 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 Carrier | USD $3,143,464 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUC0488A |
| Policy instance | 2 |
| Insurance contract or identification number | GUC0488A | | Number of Individuals Covered | 39 | | Insurance policy start date | 2010-12-01 | | Insurance policy end date | 2011-11-30 | | Total amount of commissions paid to insurance broker | USD $996 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $8,649 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
