ESSEX COUNTY CHAPTER NYSARC, INC. has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan ESSEX COUNTY CHAPTER NYSARC, INC. D/B/A MOUNTAIN LAKE SERVICES CAFETERIA PLAN
401k plan membership statisitcs for ESSEX COUNTY CHAPTER NYSARC, INC. D/B/A MOUNTAIN LAKE SERVICES CAFETERIA PLAN
| Measure | Date | Value |
|---|
| 2023: ESSEX COUNTY CHAPTER NYSARC, INC. D/B/A MOUNTAIN LAKE SERVICES CAFETERIA PLAN 2023 401k membership |
|---|
| Total participants, beginning-of-year | 2023-01-01 | 457 |
| Total number of active participants reported on line 7a of the Form 5500 | 2023-01-01 | 420 |
| Number of retired or separated participants receiving benefits | 2023-01-01 | 18 |
| Number of other retired or separated participants entitled to future benefits | 2023-01-01 | 0 |
| Total of all active and inactive participants | 2023-01-01 | 438 |
| 2022: ESSEX COUNTY CHAPTER NYSARC, INC. D/B/A MOUNTAIN LAKE SERVICES CAFETERIA PLAN 2022 401k membership |
|---|
| Total participants, beginning-of-year | 2022-01-01 | 437 |
| Total number of active participants reported on line 7a of the Form 5500 | 2022-01-01 | 457 |
| Total of all active and inactive participants | 2022-01-01 | 457 |
| 2021: ESSEX COUNTY CHAPTER NYSARC, INC. D/B/A MOUNTAIN LAKE SERVICES CAFETERIA PLAN 2021 401k membership |
|---|
| Total participants, beginning-of-year | 2021-01-01 | 482 |
| Total number of active participants reported on line 7a of the Form 5500 | 2021-01-01 | 437 |
| Total of all active and inactive participants | 2021-01-01 | 437 |
| 2020: ESSEX COUNTY CHAPTER NYSARC, INC. D/B/A MOUNTAIN LAKE SERVICES CAFETERIA PLAN 2020 401k membership |
|---|
| Total participants, beginning-of-year | 2020-01-01 | 419 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-01-01 | 482 |
| Total of all active and inactive participants | 2020-01-01 | 482 |
| Total participants | 2020-01-01 | 482 |
| 2019: ESSEX COUNTY CHAPTER NYSARC, INC. D/B/A MOUNTAIN LAKE SERVICES CAFETERIA PLAN 2019 401k membership |
|---|
| Total participants, beginning-of-year | 2019-01-01 | 422 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-01-01 | 419 |
| Total of all active and inactive participants | 2019-01-01 | 419 |
| Total participants | 2019-01-01 | 419 |
| 2018: ESSEX COUNTY CHAPTER NYSARC, INC. D/B/A MOUNTAIN LAKE SERVICES CAFETERIA PLAN 2018 401k membership |
|---|
| Total participants, beginning-of-year | 2018-01-01 | 516 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-01-01 | 422 |
| Total of all active and inactive participants | 2018-01-01 | 422 |
| Total participants | 2018-01-01 | 422 |
| 2017: ESSEX COUNTY CHAPTER NYSARC, INC. D/B/A MOUNTAIN LAKE SERVICES CAFETERIA PLAN 2017 401k membership |
|---|
| Total participants, beginning-of-year | 2017-01-01 | 577 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-01-01 | 516 |
| Total of all active and inactive participants | 2017-01-01 | 516 |
| Total participants | 2017-01-01 | 516 |
| 2016: ESSEX COUNTY CHAPTER NYSARC, INC. D/B/A MOUNTAIN LAKE SERVICES CAFETERIA PLAN 2016 401k membership |
|---|
| Total participants, beginning-of-year | 2016-01-01 | 564 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-01-01 | 577 |
| Total of all active and inactive participants | 2016-01-01 | 577 |
| Total participants | 2016-01-01 | 577 |
| 2015: ESSEX COUNTY CHAPTER NYSARC, INC. D/B/A MOUNTAIN LAKE SERVICES CAFETERIA PLAN 2015 401k membership |
|---|
| Total participants, beginning-of-year | 2015-01-01 | 558 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-01-01 | 564 |
| Total of all active and inactive participants | 2015-01-01 | 564 |
| Total participants | 2015-01-01 | 0 |
| 2014: ESSEX COUNTY CHAPTER NYSARC, INC. D/B/A MOUNTAIN LAKE SERVICES CAFETERIA PLAN 2014 401k membership |
|---|
| Total participants, beginning-of-year | 2014-01-01 | 572 |
| Total number of active participants reported on line 7a of the Form 5500 | 2014-01-01 | 558 |
| Total of all active and inactive participants | 2014-01-01 | 558 |
| Total participants | 2014-01-01 | 0 |
| 2013: ESSEX COUNTY CHAPTER NYSARC, INC. D/B/A MOUNTAIN LAKE SERVICES CAFETERIA PLAN 2013 401k membership |
|---|
| Total participants, beginning-of-year | 2013-01-01 | 576 |
| Total number of active participants reported on line 7a of the Form 5500 | 2013-01-01 | 572 |
| Total of all active and inactive participants | 2013-01-01 | 572 |
| Total participants | 2013-01-01 | 0 |
| 2012: ESSEX COUNTY CHAPTER NYSARC, INC. D/B/A MOUNTAIN LAKE SERVICES CAFETERIA PLAN 2012 401k membership |
|---|
| Total participants, beginning-of-year | 2012-01-01 | 536 |
| Total number of active participants reported on line 7a of the Form 5500 | 2012-01-01 | 576 |
| Total of all active and inactive participants | 2012-01-01 | 576 |
| Total participants | 2012-01-01 | 0 |
| 2011: ESSEX COUNTY CHAPTER NYSARC, INC. D/B/A MOUNTAIN LAKE SERVICES CAFETERIA PLAN 2011 401k membership |
|---|
| Total participants, beginning-of-year | 2011-01-01 | 502 |
| Total number of active participants reported on line 7a of the Form 5500 | 2011-01-01 | 536 |
| Total of all active and inactive participants | 2011-01-01 | 536 |
| Total participants | 2011-01-01 | 536 |
| 2009: ESSEX COUNTY CHAPTER NYSARC, INC. D/B/A MOUNTAIN LAKE SERVICES CAFETERIA PLAN 2009 401k membership |
|---|
| Total participants, beginning-of-year | 2009-01-01 | 511 |
| Total number of active participants reported on line 7a of the Form 5500 | 2009-01-01 | 520 |
| Total of all active and inactive participants | 2009-01-01 | 520 |
| Total participants | 2009-01-01 | 520 |
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 00532079 |
| Policy instance | 7 |
| Insurance contract or identification number | 00532079 | | Number of Individuals Covered | 278 | | Insurance policy start date | 2023-01-01 | | Insurance policy end date | 2023-12-31 | | Total amount of commissions paid to insurance broker | USD $2,385 | | Total amount of fees paid to insurance company | USD $1,077 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $33,025 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| HEALTHNOW NEW YORK, INC. DBA BLUESHIELD OF NORTHEASTERN NEW YORK (National Association of Insurance Commissioners NAIC id number: 55204 ) |
| Policy contract number | 287858 |
| Policy instance | 1 |
| Insurance contract or identification number | 287858 | | Number of Individuals Covered | 456 | | Insurance policy start date | 2023-01-01 | | Insurance policy end date | 2023-12-31 | | Total amount of commissions paid to insurance broker | USD $88,484 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $3,399,727 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 ) |
| Policy contract number | R0616821 |
| Policy instance | 2 |
| Insurance contract or identification number | R0616821 | | Number of Individuals Covered | 54 | | Insurance policy start date | 2023-01-01 | | Insurance policy end date | 2023-12-31 | | Total amount of commissions paid to insurance broker | USD $1,626 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | VOLUNTARY BENEFITS | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $9,567 | | 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: 71412 ) |
| Policy contract number | G000B9S8 |
| Policy instance | 3 |
| Insurance contract or identification number | G000B9S8 | | Number of Individuals Covered | 75 | | Insurance policy start date | 2023-01-01 | | Insurance policy end date | 2023-12-31 | | Total amount of commissions paid to insurance broker | USD $3,059 | | Total amount of fees paid to insurance company | USD $1,663 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $31,179 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| COMPANION LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62243 ) |
| Policy contract number | G000B9S8 |
| Policy instance | 4 |
| Insurance contract or identification number | G000B9S8 | | Number of Individuals Covered | 420 | | Insurance policy start date | 2023-01-01 | | Insurance policy end date | 2023-12-31 | | Total amount of commissions paid to insurance broker | USD $5,466 | | Total amount of fees paid to insurance company | USD $5,971 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | 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 $121,629 | | 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: 71412 ) |
| Policy contract number | G000B9S8 |
| Policy instance | 5 |
| Insurance contract or identification number | G000B9S8 | | Number of Individuals Covered | 420 | | Insurance policy start date | 2023-01-01 | | Insurance policy end date | 2023-12-31 | | Total amount of commissions paid to insurance broker | USD $1,850 | | Total amount of fees paid to insurance company | USD $919 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | AD&D LIFE | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $18,493 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| DELTA DENTAL OF NEW YORK (National Association of Insurance Commissioners NAIC id number: 55263 ) |
| Policy contract number | 22071 |
| Policy instance | 6 |
| Insurance contract or identification number | 22071 | | Number of Individuals Covered | 617 | | Insurance policy start date | 2023-01-01 | | Insurance policy end date | 2023-12-31 | | Total amount of commissions paid to insurance broker | USD $9,389 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $187,777 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HEALTHNOW NEW YORK, INC. DBA BLUESHIELD OF NORTHEASTERN NEW YORK (National Association of Insurance Commissioners NAIC id number: 55204 ) |
| Policy contract number | 11445352 |
| Policy instance | 1 |
| Insurance contract or identification number | 11445352 | | Number of Individuals Covered | 457 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $93,095 | | Total amount of fees paid to insurance company | USD $0 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $93,095 | | Insurance broker organization code? | 3 |
|
| FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 ) |
| Policy contract number | R0616821 |
| Policy instance | 2 |
| Insurance contract or identification number | R0616821 | | Number of Individuals Covered | 53 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2023-01-01 | | Total amount of commissions paid to insurance broker | USD $1,683 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | GRPACCVO | | Welfare Benefit Premiums Paid to Carrier | USD $9,899 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,683 | | Additional information about fees paid to insurance broker | BROKER COMMISSIONS | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 71412 ) |
| Policy contract number | G000B9S8 |
| Policy instance | 3 |
| Insurance contract or identification number | G000B9S8 | | Number of Individuals Covered | 70 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2023-01-01 | | Total amount of commissions paid to insurance broker | USD $2,560 | | Total amount of fees paid to insurance company | USD $2,675 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $25,597 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,560 | | Amount paid for insurance broker fees | 1783 | | Additional information about fees paid to insurance broker | OTHER SERVICE FEES | | Insurance broker organization code? | 3 |
|
| COMPANION LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62243 ) |
| Policy contract number | G000B9S8 |
| Policy instance | 4 |
| Insurance contract or identification number | G000B9S8 | | Number of Individuals Covered | 304 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2023-01-01 | | Total amount of commissions paid to insurance broker | USD $5,064 | | Total amount of fees paid to insurance company | USD $8,880 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $92,559 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,064 | | Amount paid for insurance broker fees | 5920 | | Additional information about fees paid to insurance broker | OTHER SERVICE FEES | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 71412 ) |
| Policy contract number | G000B9S8 |
| Policy instance | 5 |
| Insurance contract or identification number | G000B9S8 | | Number of Individuals Covered | 304 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2023-01-01 | | Total amount of commissions paid to insurance broker | USD $1,424 | | Total amount of fees paid to insurance company | USD $1,366 | | Other welfare benefits provided | AD&D LIFE | | Welfare Benefit Premiums Paid to Carrier | USD $14,240 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,424 | | Amount paid for insurance broker fees | 911 | | Additional information about fees paid to insurance broker | OTHER SERVICE FEES | | Insurance broker organization code? | 3 |
|
| EBPA, LLC (National Association of Insurance Commissioners NAIC id number: ) |
| Policy contract number | |
| Policy instance | 6 |
| Number of Individuals Covered | 315 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $3,959 | | Total amount of fees paid to insurance company | USD $0 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,959 | | Insurance broker organization code? | 3 |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 00532079 |
| Policy instance | 7 |
| Insurance contract or identification number | 00532079 | | Number of Individuals Covered | 259 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $2,254 | | Total amount of fees paid to insurance company | USD $1,085 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $30,762 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,254 | | Amount paid for insurance broker fees | 1085 | | Additional information about fees paid to insurance broker | OTHER FEES | | Insurance broker organization code? | 3 |
|
| EBPA, LLC (National Association of Insurance Commissioners NAIC id number: ) |
| Policy contract number | |
| Policy instance | 6 |
| Number of Individuals Covered | 303 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $3,996 | | Total amount of fees paid to insurance company | USD $0 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,996 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 71412 ) |
| Policy contract number | G000B9S8 |
| Policy instance | 5 |
| Insurance contract or identification number | G000B9S8 | | Number of Individuals Covered | 303 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $1,335 | | Total amount of fees paid to insurance company | USD $772 | | Other welfare benefits provided | AD&D LIFE | | Welfare Benefit Premiums Paid to Carrier | USD $13,353 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,335 | | Amount paid for insurance broker fees | 416 | | Additional information about fees paid to insurance broker | OTHER SERVICE FEES | | Insurance broker organization code? | 3 |
|
| COMPANION LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62243 ) |
| Policy contract number | G000B9S8 |
| Policy instance | 4 |
| Insurance contract or identification number | G000B9S8 | | Number of Individuals Covered | 303 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2022-01-01 | | Total amount of commissions paid to insurance broker | USD $4,920 | | Total amount of fees paid to insurance company | USD $4,900 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $86,796 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,920 | | Amount paid for insurance broker fees | 2638 | | Additional information about fees paid to insurance broker | OTHER SERVICE FEES | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 71412 ) |
| Policy contract number | G000B9S8 |
| Policy instance | 3 |
| Insurance contract or identification number | G000B9S8 | | Number of Individuals Covered | 72 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $2,674 | | Total amount of fees paid to insurance company | USD $1,276 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $26,741 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,674 | | Amount paid for insurance broker fees | 687 | | Additional information about fees paid to insurance broker | OTHER SERVICE FEES | | Insurance broker organization code? | 3 |
|
| FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 ) |
| Policy contract number | R0616821 |
| Policy instance | 2 |
| Insurance contract or identification number | R0616821 | | Number of Individuals Covered | 54 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2022-01-01 | | Total amount of commissions paid to insurance broker | USD $1,625 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | GRPACCVO | | Welfare Benefit Premiums Paid to Carrier | USD $9,561 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,625 | | Additional information about fees paid to insurance broker | BROKER COMMISSIONS | | Insurance broker organization code? | 3 |
|
| HEALTHNOW NEW YORK, INC. DBA BLUESHIELD OF NORTHEASTERN NEW YORK (National Association of Insurance Commissioners NAIC id number: 55204 ) |
| Policy contract number | 11445352 |
| Policy instance | 1 |
| Insurance contract or identification number | 11445352 | | Number of Individuals Covered | 437 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $77,591 | | Total amount of fees paid to insurance company | USD $0 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $77,591 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 71412 ) |
| Policy contract number | G000B9S8 |
| Policy instance | 5 |
| Insurance contract or identification number | G000B9S8 | | Number of Individuals Covered | 413 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $3,452 | | Total amount of fees paid to insurance company | USD $2,365 | | Temporary Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $34,518 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,452 | | Amount paid for insurance broker fees | 1419 | | Insurance broker organization code? | 5 | | Additional information about fees paid to insurance broker | OTHER SERVICE FEES |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 00014790 |
| Policy instance | 4 |
| Insurance contract or identification number | 00014790 | | Number of Individuals Covered | 277 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $2,331 | | Total amount of fees paid to insurance company | USD $2,231 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $32,129 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,331 | | Amount paid for insurance broker fees | 2231 | | Insurance broker organization code? | 5 |
|
| EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 ) |
| Policy contract number | 00122477 |
| Policy instance | 3 |
| Insurance contract or identification number | 00122477 | | Number of Individuals Covered | 302 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $84,967 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $2,829,730 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $84,967 | | Insurance broker organization code? | 5 |
|
| COMPANION LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62243 ) |
| Policy contract number | G000B9S8 |
| Policy instance | 2 |
| Insurance contract or identification number | G000B9S8 | | Number of Individuals Covered | 337 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $4,804 | | Total amount of fees paid to insurance company | USD $5,143 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $82,173 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,804 | | Amount paid for insurance broker fees | 3086 | | Additional information about fees paid to insurance broker | OTHER SERVICE FEES | | Insurance broker organization code? | 3 |
|
| CBA BLUE (National Association of Insurance Commissioners NAIC id number: 0 ) |
| Policy contract number | 00263 |
| Policy instance | 1 |
| Insurance contract or identification number | 00263 | | Number of Individuals Covered | 335 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of fees paid to insurance company | USD $17,027 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 13020 | | Additional information about fees paid to insurance broker | CONTRACT ADMINISTRATION | | Insurance broker organization code? | 5 |
|
| CBA BLUE (National Association of Insurance Commissioners NAIC id number: 0 ) |
| Policy contract number | 00263 |
| Policy instance | 1 |
| Insurance contract or identification number | 00263 | | Number of Individuals Covered | 292 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of fees paid to insurance company | USD $17,650 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 13497 | | Additional information about fees paid to insurance broker | CONTRACT ADMINISTRATION | | Insurance broker organization code? | 5 |
|
| COMPANION LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62243 ) |
| Policy contract number | G000B9S8 |
| Policy instance | 2 |
| Insurance contract or identification number | G000B9S8 | | Number of Individuals Covered | 356 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $4,455 | | Total amount of fees paid to insurance company | USD $2,701 | | Life Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,455 | | Amount paid for insurance broker fees | 2701 | | Additional information about fees paid to insurance broker | OTHER SERVICE FEES | | Insurance broker organization code? | 3 |
|
| EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 ) |
| Policy contract number | 00122477 |
| Policy instance | 3 |
| Insurance contract or identification number | 00122477 | | Number of Individuals Covered | 305 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $83,763 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $2,756,261 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $83,763 | | Insurance broker organization code? | 5 |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 00014790 |
| Policy instance | 4 |
| Insurance contract or identification number | 00014790 | | Number of Individuals Covered | 262 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $2,241 | | Total amount of fees paid to insurance company | USD $1,887 | | Vision Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,241 | | Amount paid for insurance broker fees | 1887 | | Insurance broker organization code? | 5 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 71412 ) |
| Policy contract number | G000B9S8 |
| Policy instance | 5 |
| Insurance contract or identification number | G000B9S8 | | Number of Individuals Covered | 406 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $3,118 | | Total amount of fees paid to insurance company | USD $1,454 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,118 | | Amount paid for insurance broker fees | 1454 | | Insurance broker organization code? | 5 |
|
| CBA BLUE (National Association of Insurance Commissioners NAIC id number: 0 ) |
| Policy contract number | 00263 |
| Policy instance | 1 |
| Insurance contract or identification number | 00263 | | Number of Individuals Covered | 320 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $14,658 | | Total amount of fees paid to insurance company | USD $4,510 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $14,658 | | Additional information about fees paid to insurance broker | CONTRACT ADMINISTRATION | | Insurance broker organization code? | 5 | | Amount paid for insurance broker fees | 4510 |
|
| COMPANION LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62243 ) |
| Policy contract number | G000B9S8 |
| Policy instance | 2 |
| Insurance contract or identification number | G000B9S8 | | Number of Individuals Covered | 374 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $4,591 | | Life Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,591 | | Insurance broker organization code? | 3 |
|
| EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 ) |
| Policy contract number | 00122477 |
| Policy instance | 3 |
| Insurance contract or identification number | 00122477 | | Number of Individuals Covered | 211 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $100,200 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $3,839,456 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $100,200 | | Insurance broker organization code? | 5 |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 00014790 |
| Policy instance | 4 |
| Insurance contract or identification number | 00014790 | | Number of Individuals Covered | 285 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $2,274 | | Total amount of fees paid to insurance company | USD $2,044 | | Vision Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,252 | | Amount paid for insurance broker fees | 2044 | | Insurance broker organization code? | 5 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 71412 ) |
| Policy contract number | G000B9S8 |
| Policy instance | 5 |
| Insurance contract or identification number | G000B9S8 | | Number of Individuals Covered | 374 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $8,229 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,229 | | Insurance broker organization code? | 5 |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 00014790 |
| Policy instance | 4 |
| Insurance contract or identification number | 00014790 | | Number of Individuals Covered | 279 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $2,207 | | Vision Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,207 | | Insurance broker organization code? | 5 | | Insurance broker name | ROBERT G RELPH AGENCY INC |
|
| EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 ) |
| Policy contract number | 406385 |
| Policy instance | 3 |
| Insurance contract or identification number | 406385 | | Number of Individuals Covered | 375 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $110,509 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $4,528,065 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $110,509 | | Insurance broker organization code? | 5 | | Insurance broker name | ROBERT G RELPH AGENCY INC. |
|
| ANTHEM LIFE & DISABILITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 13573 ) |
| Policy contract number | NY0030 |
| Policy instance | 2 |
| Insurance contract or identification number | NY0030 | | Number of Individuals Covered | 434 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $5,198 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,198 | | Insurance broker organization code? | 3 | | Insurance broker name | ROBERT G RELPH AGENCY INC. |
|
| CBA BLUE (National Association of Insurance Commissioners NAIC id number: 0 ) |
| Policy contract number | 00263 |
| Policy instance | 1 |
| Insurance contract or identification number | 00263 | | Number of Individuals Covered | 402 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of fees paid to insurance company | USD $20,918 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 15996 | | Additional information about fees paid to insurance broker | CONTRACT ADMINISTRATION | | Insurance broker organization code? | 5 | | Insurance broker name | NORTHERN INSURING AGENCY |
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