PRESTOLITE ELECTRIC, LLC has sponsored the creation of one or more 401k plans.
| Measure | Date | Value |
|---|
| 2022: GROUP BENEFIT PLAN 2022 401k membership |
|---|
| Total participants, beginning-of-year | 2022-01-01 | 344 |
| Total number of active participants reported on line 7a of the Form 5500 | 2022-01-01 | 341 |
| Number of retired or separated participants receiving benefits | 2022-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2022-01-01 | 0 |
| Total of all active and inactive participants | 2022-01-01 | 341 |
| 2021: GROUP BENEFIT PLAN 2021 401k membership |
|---|
| Total participants, beginning-of-year | 2021-01-01 | 436 |
| Total number of active participants reported on line 7a of the Form 5500 | 2021-01-01 | 344 |
| Number of retired or separated participants receiving benefits | 2021-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2021-01-01 | 0 |
| Total of all active and inactive participants | 2021-01-01 | 344 |
| 2020: GROUP BENEFIT PLAN 2020 401k membership |
|---|
| Total participants, beginning-of-year | 2020-01-01 | 463 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-01-01 | 436 |
| Number of retired or separated participants receiving benefits | 2020-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2020-01-01 | 0 |
| Total of all active and inactive participants | 2020-01-01 | 436 |
| 2019: GROUP BENEFIT PLAN 2019 401k membership |
|---|
| Total participants, beginning-of-year | 2019-01-01 | 466 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-01-01 | 463 |
| Number of retired or separated participants receiving benefits | 2019-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2019-01-01 | 0 |
| Total of all active and inactive participants | 2019-01-01 | 463 |
| 2018: GROUP BENEFIT PLAN 2018 401k membership |
|---|
| Total participants, beginning-of-year | 2018-01-01 | 508 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-01-01 | 466 |
| Number of retired or separated participants receiving benefits | 2018-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2018-01-01 | 0 |
| Total of all active and inactive participants | 2018-01-01 | 466 |
| 2017: GROUP BENEFIT PLAN 2017 401k membership |
|---|
| Total participants, beginning-of-year | 2017-01-01 | 548 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-01-01 | 508 |
| Number of retired or separated participants receiving benefits | 2017-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2017-01-01 | 0 |
| Total of all active and inactive participants | 2017-01-01 | 508 |
| 2016: GROUP BENEFIT PLAN 2016 401k membership |
|---|
| Total participants, beginning-of-year | 2016-01-01 | 634 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-01-01 | 548 |
| Number of retired or separated participants receiving benefits | 2016-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2016-01-01 | 0 |
| Total of all active and inactive participants | 2016-01-01 | 548 |
| 2015: GROUP BENEFIT PLAN 2015 401k membership |
|---|
| Total participants, beginning-of-year | 2015-01-01 | 717 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-01-01 | 634 |
| Number of retired or separated participants receiving benefits | 2015-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2015-01-01 | 0 |
| Total of all active and inactive participants | 2015-01-01 | 634 |
| 2014: GROUP BENEFIT PLAN 2014 401k membership |
|---|
| Total participants, beginning-of-year | 2014-01-01 | 893 |
| Total number of active participants reported on line 7a of the Form 5500 | 2014-01-01 | 717 |
| Number of retired or separated participants receiving benefits | 2014-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2014-01-01 | 0 |
| Total of all active and inactive participants | 2014-01-01 | 717 |
| 2013: GROUP BENEFIT PLAN 2013 401k membership |
|---|
| Total participants, beginning-of-year | 2013-01-01 | 939 |
| Total number of active participants reported on line 7a of the Form 5500 | 2013-01-01 | 893 |
| Total of all active and inactive participants | 2013-01-01 | 893 |
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 30025262 |
| Policy instance | 3 |
| Insurance contract or identification number | 30025262 | | Number of Individuals Covered | 85 | | Insurance policy start date | 2021-04-01 | | Insurance policy end date | 2022-03-31 | | Total amount of commissions paid to insurance broker | USD $366 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $14,782 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $366 | | Additional information about fees paid to insurance broker | SALES & SERVICE | | 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 | 00401365 |
| Policy instance | 1 |
| Insurance contract or identification number | 00401365 | | Number of Individuals Covered | 293 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of fees paid to insurance company | USD $489,020 | | Other welfare benefits provided | POS | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 489020 | | Additional information about fees paid to insurance broker | SALES & SERVICE | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 64548 ) |
| Policy contract number | OK 965553 |
| Policy instance | 2 |
| Insurance contract or identification number | OK 965553 | | Insurance policy start date | 2022-04-01 | | Insurance policy end date | 2022-04-01 | | Total amount of fees paid to insurance company | USD $104 | | Other welfare benefits provided | ACCIDENTAL DEATH | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 104 | | Additional information about fees paid to insurance broker | SALES AND SERVICE OVERRIDE | | Insurance broker organization code? | 3 |
|
| LINCOLN LIFE AND ANNUITY CO OF NY (National Association of Insurance Commissioners NAIC id number: 62057 ) |
| Policy contract number | 00400269242 |
| Policy instance | 12 |
| Insurance contract or identification number | 00400269242 | | Number of Individuals Covered | 86 | | Insurance policy start date | 2022-04-01 | | Insurance policy end date | 2023-03-31 | | Total amount of commissions paid to insurance broker | USD $790 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $7,897 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $790 | | Additional information about fees paid to insurance broker | SALES AND SERVICE | | Insurance broker organization code? | 3 |
|
| CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 ) |
| Policy contract number | NYD074864 |
| Policy instance | 5 |
| Insurance contract or identification number | NYD074864 | | Insurance policy start date | 2022-04-01 | | Insurance policy end date | 2022-04-01 | | Total amount of fees paid to insurance company | USD $1,891 | | Temporary Disability 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 | 1891 | | Additional information about fees paid to insurance broker | SALES AND SERVICE OVERRIDE | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 64548 ) |
| Policy contract number | FLX963926 |
| Policy instance | 4 |
| Insurance contract or identification number | FLX963926 | | Insurance policy start date | 2022-04-01 | | Insurance policy end date | 2022-04-01 | | Total amount of commissions paid to insurance broker | USD $1,723 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,233 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,723 | | Additional information about fees paid to insurance broker | SALES & SERVICE OVERRIDE | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 ) |
| Policy contract number | 0001971 |
| Policy instance | 6 |
| Insurance contract or identification number | 0001971 | | Number of Individuals Covered | 341 | | Insurance policy start date | 2022-04-01 | | Insurance policy end date | 2023-03-31 | | Total amount of commissions paid to insurance broker | USD $3,688 | | 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 $3,688 | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 64548 ) |
| Policy contract number | VDT960824 |
| Policy instance | 7 |
| Insurance contract or identification number | VDT960824 | | Insurance policy start date | 2022-04-01 | | Insurance policy end date | 2022-04-01 | | Total amount of fees paid to insurance company | USD $476 | | Long Term Disability 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 | 476 | | Additional information about fees paid to insurance broker | SALES AND SERVICE OVERRIDE | | Insurance broker organization code? | 3 |
|
| LINCOLN LIFE AND ANNUITY CO OF NY (National Association of Insurance Commissioners NAIC id number: 62057 ) |
| Policy contract number | 000010269223 |
| Policy instance | 8 |
| Insurance contract or identification number | 000010269223 | | Number of Individuals Covered | 230 | | Insurance policy start date | 2022-04-01 | | Insurance policy end date | 2023-03-31 | | Total amount of commissions paid to insurance broker | USD $2,593 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $34,131 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,593 | | Additional information about fees paid to insurance broker | SALES & SERVICE | | Insurance broker organization code? | 3 |
|
| LINCOLN LIFE AND ANNUITY CO OF NY (National Association of Insurance Commissioners NAIC id number: 62057 ) |
| Policy contract number | 000010269224 |
| Policy instance | 9 |
| Insurance contract or identification number | 000010269224 | | Number of Individuals Covered | 107 | | Insurance policy start date | 2022-04-01 | | Insurance policy end date | 2023-06-21 | | Total amount of commissions paid to insurance broker | USD $3,085 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $20,566 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,085 | | Additional information about fees paid to insurance broker | SALES AND SERVICE | | Insurance broker organization code? | 3 |
|
| LINCOLN LIFE AND ANNUITY CO OF NY (National Association of Insurance Commissioners NAIC id number: 62057 ) |
| Policy contract number | 00400269225 |
| Policy instance | 11 |
| Insurance contract or identification number | 00400269225 | | Number of Individuals Covered | 40 | | Insurance policy start date | 2022-04-01 | | Insurance policy end date | 2023-03-31 | | Total amount of commissions paid to insurance broker | USD $5,940 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $39,598 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,940 | | Additional information about fees paid to insurance broker | SALES AND SERVICE | | Insurance broker organization code? | 3 |
|
| LINCOLN LIFE AND ANNUITY CO OF NY (National Association of Insurance Commissioners NAIC id number: 62057 ) |
| Policy contract number | 000403008096 |
| Policy instance | 10 |
| Insurance contract or identification number | 000403008096 | | Number of Individuals Covered | 42 | | Insurance policy start date | 2022-04-01 | | Insurance policy end date | 2023-03-31 | | Total amount of commissions paid to insurance broker | USD $424 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $2,828 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $424 | | Additional information about fees paid to insurance broker | SALES AND SERVICE | | 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 | 00401365 |
| Policy instance | 1 |
| Insurance contract or identification number | 00401365 | | Number of Individuals Covered | 305 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of fees paid to insurance company | USD $2,519 | | Other welfare benefits provided | POS | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 2519 | | Additional information about fees paid to insurance broker | SALES & SERVICE | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 64548 ) |
| Policy contract number | LK 750929 |
| Policy instance | 4 |
| Insurance contract or identification number | LK 750929 | | Insurance policy start date | 2021-04-01 | | Insurance policy end date | 2022-04-01 | | Total amount of commissions paid to insurance broker | USD $96 | | Total amount of fees paid to insurance company | USD $64 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $958 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $96 | | Amount paid for insurance broker fees | 64 | | Additional information about fees paid to insurance broker | SALES & SERVICE OVERRIDE | | Insurance broker organization code? | 3 |
|
| CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 ) |
| Policy contract number | NYD074864 |
| Policy instance | 6 |
| Insurance contract or identification number | NYD074864 | | Number of Individuals Covered | 178 | | Insurance policy start date | 2021-04-01 | | Insurance policy end date | 2021-04-01 | | Total amount of commissions paid to insurance broker | USD $8,971 | | Total amount of fees paid to insurance company | USD $1,479 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $89,706 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,971 | | Amount paid for insurance broker fees | 1479 | | Additional information about fees paid to insurance broker | SALES AND SERVICE OVERRIDE | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 64548 ) |
| Policy contract number | VDT960824 |
| Policy instance | 8 |
| Insurance contract or identification number | VDT960824 | | Number of Individuals Covered | 60 | | Insurance policy start date | 2021-04-01 | | Insurance policy end date | 2022-04-01 | | Total amount of commissions paid to insurance broker | USD $3,836 | | Total amount of fees paid to insurance company | USD $485 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $24,193 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,836 | | Amount paid for insurance broker fees | 485 | | Additional information about fees paid to insurance broker | SALES AND SERVICE OVERRIDE | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 64548 ) |
| Policy contract number | OK 965553 |
| Policy instance | 2 |
| Insurance contract or identification number | OK 965553 | | Number of Individuals Covered | 126 | | Insurance policy start date | 2021-04-01 | | Insurance policy end date | 2022-04-01 | | Total amount of commissions paid to insurance broker | USD $580 | | Total amount of fees paid to insurance company | USD $123 | | Other welfare benefits provided | ACCIDENTAL DEATH | | Welfare Benefit Premiums Paid to Carrier | USD $5,521 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $580 | | Amount paid for insurance broker fees | 123 | | Additional information about fees paid to insurance broker | SALES & SERVICE OVERRIDE | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 ) |
| Policy contract number | 0001971 |
| Policy instance | 7 |
| Insurance contract or identification number | 0001971 | | Number of Individuals Covered | 344 | | Insurance policy start date | 2021-04-01 | | Insurance policy end date | 2022-03-31 | | Total amount of commissions paid to insurance broker | USD $2,867 | | 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 $2,867 | | Insurance broker organization code? | 3 |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 30025262 |
| Policy instance | 3 |
| Insurance contract or identification number | 30025262 | | Number of Individuals Covered | 90 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $917 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $15,672 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $917 | | Additional information about fees paid to insurance broker | SALES & SERVICE | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 64548 ) |
| Policy contract number | FLX963926 |
| Policy instance | 5 |
| Insurance contract or identification number | FLX963926 | | Number of Individuals Covered | 34 | | Insurance policy start date | 2021-04-01 | | Insurance policy end date | 2022-04-01 | | Total amount of commissions paid to insurance broker | USD $8,988 | | Total amount of fees paid to insurance company | USD $1,965 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $94,806 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,988 | | Amount paid for insurance broker fees | 1965 | | Additional information about fees paid to insurance broker | SALES & SERVICE OVERRIDE | | Insurance broker organization code? | 3 |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 30025262 |
| Policy instance | 12 |
| Insurance contract or identification number | 30025262 | | Number of Individuals Covered | 109 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $318 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $18,049 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $318 | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 64548 ) |
| Policy contract number | 03292A |
| Policy instance | 11 |
| Insurance contract or identification number | 03292A | | Number of Individuals Covered | 2 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $22 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $415 | | 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 | | Additional information about fees paid to insurance broker | SALES AND SERVICE | | 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 | 00401365 |
| Policy instance | 1 |
| Insurance contract or identification number | 00401365 | | Number of Individuals Covered | 406 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Other welfare benefits provided | POS | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 64548 ) |
| Policy contract number | OK 965553 |
| Policy instance | 2 |
| Insurance contract or identification number | OK 965553 | | Number of Individuals Covered | 237 | | Insurance policy start date | 2020-04-01 | | Insurance policy end date | 2021-04-01 | | Total amount of commissions paid to insurance broker | USD $447 | | Total amount of fees paid to insurance company | USD $60 | | Other welfare benefits provided | ACCIDENTAL DEATH | | Welfare Benefit Premiums Paid to Carrier | USD $4,472 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $447 | | Amount paid for insurance broker fees | 60 | | Additional information about fees paid to insurance broker | SALES & SERVICE OVERRIDE | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 64548 ) |
| Policy contract number | FLX963926 |
| Policy instance | 5 |
| Insurance contract or identification number | FLX963926 | | Number of Individuals Covered | 237 | | Insurance policy start date | 2020-04-01 | | Insurance policy end date | 2021-04-01 | | Total amount of commissions paid to insurance broker | USD $7,330 | | Total amount of fees paid to insurance company | USD $591 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $78,228 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,330 | | Amount paid for insurance broker fees | 591 | | Additional information about fees paid to insurance broker | SALES & SERVICE OVERRIDE | | Insurance broker organization code? | 3 |
|
| CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 ) |
| Policy contract number | NYD074864 |
| Policy instance | 6 |
| Insurance contract or identification number | NYD074864 | | Number of Individuals Covered | 193 | | Insurance policy start date | 2020-04-01 | | Insurance policy end date | 2021-04-01 | | Total amount of commissions paid to insurance broker | USD $5,429 | | Total amount of fees paid to insurance company | USD $719 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $54,288 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,429 | | Amount paid for insurance broker fees | 719 | | Additional information about fees paid to insurance broker | SALES AND SERVICE OVERRIDE | | Insurance broker organization code? | 3 |
|
| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
| Policy contract number | 03292A |
| Policy instance | 10 |
| Insurance contract or identification number | 03292A | | Number of Individuals Covered | 2 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $1,616 | | Health Insurance Welfare Benefit | Yes | | Other welfare benefits provided | EVACUATION | | Welfare Benefit Premiums Paid to Carrier | USD $22,290 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,616 | | Additional information about fees paid to insurance broker | SALES AND SERVICE | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 64548 ) |
| Policy contract number | VDT960824 |
| Policy instance | 8 |
| Insurance contract or identification number | VDT960824 | | Number of Individuals Covered | 119 | | Insurance policy start date | 2020-04-01 | | Insurance policy end date | 2021-04-01 | | Total amount of commissions paid to insurance broker | USD $2,739 | | Total amount of fees paid to insurance company | USD $255 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $18,259 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,739 | | Amount paid for insurance broker fees | 255 | | Additional information about fees paid to insurance broker | SALES AND SERVICE OVERRIDE | | Insurance broker organization code? | 3 |
|
| ACE AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 22667 ) |
| Policy contract number | ADDN10845762 |
| Policy instance | 9 |
| Insurance contract or identification number | ADDN10845762 | | Number of Individuals Covered | 90 | | Insurance policy start date | 2020-07-01 | | Insurance policy end date | 2021-07-01 | | Total amount of commissions paid to insurance broker | USD $778 | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $7,782 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $778 | | Additional information about fees paid to insurance broker | SERVICES | | Insurance broker organization code? | 3 |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 30025262 |
| Policy instance | 3 |
| Insurance contract or identification number | 30025262 | | Number of Individuals Covered | 108 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $719 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $18,049 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $719 | | Additional information about fees paid to insurance broker | SALES & SERVICE | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 ) |
| Policy contract number | 0001971 |
| Policy instance | 7 |
| Insurance contract or identification number | 0001971 | | Number of Individuals Covered | 436 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $3,468 | | Total amount of fees paid to insurance company | USD $515 | | 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 $3,468 | | Amount paid for insurance broker fees | 515 | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 64548 ) |
| Policy contract number | LK 750929 |
| Policy instance | 4 |
| Insurance contract or identification number | LK 750929 | | Number of Individuals Covered | 11 | | Insurance policy start date | 2020-04-01 | | Insurance policy end date | 2021-04-01 | | Total amount of commissions paid to insurance broker | USD $209 | | Total amount of fees paid to insurance company | USD $32 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $2,092 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $209 | | Amount paid for insurance broker fees | 32 | | Additional information about fees paid to insurance broker | SALES & SERVICE OVERRIDE | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 ) |
| Policy contract number | 0001971 |
| Policy instance | 7 |
| Insurance contract or identification number | 0001971 | | Number of Individuals Covered | 463 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $3,708 | | 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 $3,708 | | 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 | 00401365 |
| Policy instance | 1 |
| Insurance contract or identification number | 00401365 | | Number of Individuals Covered | 439 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Other welfare benefits provided | POS | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 64548 ) |
| Policy contract number | OK 965553 |
| Policy instance | 2 |
| Insurance contract or identification number | OK 965553 | | Number of Individuals Covered | 249 | | Insurance policy start date | 2019-04-01 | | Insurance policy end date | 2020-04-01 | | Total amount of commissions paid to insurance broker | USD $498 | | Other welfare benefits provided | ACCIDENTAL DEATH | | Welfare Benefit Premiums Paid to Carrier | USD $6,175 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $498 | | Additional information about fees paid to insurance broker | SALES & SERVICE OVERRIDE | | Insurance broker organization code? | 3 |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 30025262 |
| Policy instance | 3 |
| Insurance contract or identification number | 30025262 | | Number of Individuals Covered | 112 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $1,069 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $18,971 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,069 | | Additional information about fees paid to insurance broker | SALES & SERVICE | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 64548 ) |
| Policy contract number | LK 750929 |
| Policy instance | 4 |
| Insurance contract or identification number | LK 750929 | | Number of Individuals Covered | 13 | | Insurance policy start date | 2019-04-01 | | Insurance policy end date | 2020-04-01 | | Total amount of commissions paid to insurance broker | USD $260 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $3,108 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $260 | | Additional information about fees paid to insurance broker | SALES & SERVICE OVERRIDE | | Insurance broker organization code? | 3 |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 30025262 |
| Policy instance | 12 |
| Insurance contract or identification number | 30025262 | | Number of Individuals Covered | 3 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Vision Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 64548 ) |
| Policy contract number | FLX963926 |
| Policy instance | 5 |
| Insurance contract or identification number | FLX963926 | | Number of Individuals Covered | 249 | | Insurance policy start date | 2019-04-01 | | Insurance policy end date | 2020-04-01 | | Total amount of commissions paid to insurance broker | USD $5,943 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $80,695 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,943 | | Additional information about fees paid to insurance broker | SALES & SERVICE OVERRIDE | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 64548 ) |
| Policy contract number | VDT960824 |
| Policy instance | 8 |
| Insurance contract or identification number | VDT960824 | | Number of Individuals Covered | 122 | | Insurance policy start date | 2019-04-01 | | Insurance policy end date | 2020-04-01 | | Total amount of commissions paid to insurance broker | USD $5,632 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $25,521 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,632 | | Additional information about fees paid to insurance broker | SALES AND SERVICE OVERRIDE | | Insurance broker organization code? | 3 |
|
| ACE AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 22667 ) |
| Policy contract number | N10845762 |
| Policy instance | 9 |
| Insurance contract or identification number | N10845762 | | Number of Individuals Covered | 46 | | Insurance policy start date | 2019-07-01 | | Insurance policy end date | 2020-07-01 | | Total amount of commissions paid to insurance broker | USD $778 | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $7,782 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $778 | | Additional information about fees paid to insurance broker | SERVICES | | Insurance broker organization code? | 3 |
|
| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
| Policy contract number | 03292A |
| Policy instance | 10 |
| Insurance contract or identification number | 03292A | | Number of Individuals Covered | 2 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $4,223 | | Health Insurance Welfare Benefit | Yes | | Other welfare benefits provided | EVACUATION | | Welfare Benefit Premiums Paid to Carrier | USD $52,790 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,223 | | Additional information about fees paid to insurance broker | SALES AND SERVICE | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 64548 ) |
| Policy contract number | 03292A |
| Policy instance | 11 |
| Insurance contract or identification number | 03292A | | Number of Individuals Covered | 2 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $1,199 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 ) |
| Policy contract number | NYD074864 |
| Policy instance | 6 |
| Insurance contract or identification number | NYD074864 | | Number of Individuals Covered | 201 | | Insurance policy start date | 2019-04-01 | | Insurance policy end date | 2020-04-01 | | Total amount of commissions paid to insurance broker | USD $7,996 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $79,960 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,996 | | Additional information about fees paid to insurance broker | SALES AND SERVICE OVERRIDE | | Insurance broker organization code? | 3 |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 30025262 |
| Policy instance | 3 |
| Insurance contract or identification number | 30025262 | | Number of Individuals Covered | 113 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $17,623 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 64548 ) |
| Policy contract number | OK 965553 |
| Policy instance | 2 |
| Insurance contract or identification number | OK 965553 | | Number of Individuals Covered | 277 | | Insurance policy start date | 2018-04-01 | | Insurance policy end date | 2019-04-01 | | Total amount of commissions paid to insurance broker | USD $682 | | Total amount of fees paid to insurance company | USD $65 | | Other welfare benefits provided | ACCIDENTAL DEATH | | Welfare Benefit Premiums Paid to Carrier | USD $6,821 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $682 | | Amount paid for insurance broker fees | 65 | | Additional information about fees paid to insurance broker | SALES & SERVICE OVERRIDE | | 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 | 00401365 |
| Policy instance | 1 |
| Insurance contract or identification number | 00401365 | | Number of Individuals Covered | 454 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Other welfare benefits provided | POS | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 64548 ) |
| Policy contract number | LK 750929 |
| Policy instance | 4 |
| Insurance contract or identification number | LK 750929 | | Number of Individuals Covered | 13 | | Insurance policy start date | 2018-04-01 | | Insurance policy end date | 2019-04-01 | | Total amount of commissions paid to insurance broker | USD $295 | | Total amount of fees paid to insurance company | USD $24 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $2,947 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $295 | | Amount paid for insurance broker fees | 24 | | Additional information about fees paid to insurance broker | SALES & SERVICE OVERRIDE | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 64548 ) |
| Policy contract number | FLX963926 |
| Policy instance | 5 |
| Insurance contract or identification number | FLX963926 | | Number of Individuals Covered | 277 | | Insurance policy start date | 2018-04-01 | | Insurance policy end date | 2019-04-01 | | Total amount of commissions paid to insurance broker | USD $10,916 | | Total amount of fees paid to insurance company | USD $977 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $114,068 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $10,916 | | Amount paid for insurance broker fees | 977 | | Additional information about fees paid to insurance broker | SALES & SERVICE OVERRIDE | | Insurance broker organization code? | 3 |
|
| CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 ) |
| Policy contract number | NYD074864 |
| Policy instance | 6 |
| Insurance contract or identification number | NYD074864 | | Number of Individuals Covered | 224 | | Insurance policy start date | 2018-04-01 | | Insurance policy end date | 2019-04-01 | | Total amount of commissions paid to insurance broker | USD $6,278 | | Total amount of fees paid to insurance company | USD $423 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $62,779 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,278 | | Amount paid for insurance broker fees | 423 | | Additional information about fees paid to insurance broker | SALES AND SERVICE OVERRIDE | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 ) |
| Policy contract number | 0001971 |
| Policy instance | 7 |
| Insurance contract or identification number | 0001971 | | Number of Individuals Covered | 466 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $3,831 | | 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 $3,831 | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 64548 ) |
| Policy contract number | VDT960824 |
| Policy instance | 8 |
| Insurance contract or identification number | VDT960824 | | Number of Individuals Covered | 134 | | Insurance policy start date | 2018-04-01 | | Insurance policy end date | 2019-04-01 | | Total amount of commissions paid to insurance broker | USD $4,243 | | Total amount of fees paid to insurance company | USD $278 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $28,290 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,243 | | Amount paid for insurance broker fees | 278 | | Additional information about fees paid to insurance broker | SALES AND SERVICE OVERRIDE | | Insurance broker organization code? | 3 |
|
| ACE AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 22667 ) |
| Policy contract number | ADD N10845762R |
| Policy instance | 9 |
| Insurance contract or identification number | ADD N10845762R | | Number of Individuals Covered | 50 | | Insurance policy start date | 2018-07-01 | | Insurance policy end date | 2019-07-01 | | Total amount of commissions paid to insurance broker | USD $778 | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $7,782 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $778 | | Additional information about fees paid to insurance broker | SERVICES | | Insurance broker organization code? | 3 |
|
| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
| Policy contract number | 03292A |
| Policy instance | 10 |
| Insurance contract or identification number | 03292A | | Number of Individuals Covered | 3 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $4,734 | | Health Insurance Welfare Benefit | Yes | | Other welfare benefits provided | EVACUATION | | Welfare Benefit Premiums Paid to Carrier | USD $59,172 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,734 | | Additional information about fees paid to insurance broker | SALES AND SERVICE | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 64548 ) |
| Policy contract number | 03292A |
| Policy instance | 11 |
| Insurance contract or identification number | 03292A | | Number of Individuals Covered | 3 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $115 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $1,442 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $115 | | Additional information about fees paid to insurance broker | SALES AND SERVICE | | Insurance broker organization code? | 3 |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 30025262 |
| Policy instance | 12 |
| Insurance contract or identification number | 30025262 | | Number of Individuals Covered | 3 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $1,021 | | 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 $1,021 | | Additional information about fees paid to insurance broker | SALES/SERVICE | | Insurance broker organization code? | 3 |
|
| CIGNA GROUP INSURANCE (National Association of Insurance Commissioners NAIC id number: 64548 ) |
| Policy contract number | NYD074864 |
| Policy instance | 6 |
| Insurance contract or identification number | NYD074864 | | Number of Individuals Covered | 223 | | Insurance policy start date | 2017-04-01 | | Insurance policy end date | 2018-04-01 | | Total amount of commissions paid to insurance broker | USD $4,617 | | Total amount of fees paid to insurance company | USD $840 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $46,167 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,617 | | Amount paid for insurance broker fees | 840 | | Additional information about fees paid to insurance broker | SALES AND SERVICE | | Insurance broker organization code? | 3 | | Insurance broker name | USI INSURANCE SERVICES NA |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 64548 ) |
| Policy contract number | FLX963926 |
| Policy instance | 5 |
| Insurance contract or identification number | FLX963926 | | Number of Individuals Covered | 268 | | Insurance policy start date | 2017-04-01 | | Insurance policy end date | 2018-04-01 | | Total amount of commissions paid to insurance broker | USD $8,945 | | Total amount of fees paid to insurance company | USD $2,075 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $93,895 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,945 | | Amount paid for insurance broker fees | 2075 | | Additional information about fees paid to insurance broker | SALES & SERVICE | | Insurance broker organization code? | 3 | | Insurance broker name | USI INSURANCE SERVICES NA |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 64548 ) |
| Policy contract number | LK 750929 |
| Policy instance | 4 |
| Insurance contract or identification number | LK 750929 | | Number of Individuals Covered | 11 | | Insurance policy start date | 2017-04-01 | | Insurance policy end date | 2018-04-01 | | Total amount of commissions paid to insurance broker | USD $218 | | Total amount of fees paid to insurance company | USD $52 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $2,181 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $218 | | Amount paid for insurance broker fees | 52 | | Additional information about fees paid to insurance broker | SALES & SERVICE SALES AND SERVICE | | Insurance broker organization code? | 3 | | Insurance broker name | USI INSURANCE SERVICES NA |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 30025262 |
| Policy instance | 3 |
| Insurance contract or identification number | 30025262 | | Number of Individuals Covered | 110 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $1,008 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $17,257 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $710 | | Additional information about fees paid to insurance broker | SALES AND SERVICE | | Insurance broker organization code? | 3 | | Insurance broker name | WELLS FARGO INSURANCE SERVICES |
|
| DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 ) |
| Policy contract number | 0001971 |
| Policy instance | 7 |
| Insurance contract or identification number | 0001971 | | Number of Individuals Covered | 508 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $4,053 | | 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 $4,053 | | Insurance broker organization code? | 3 | | Insurance broker name | USI INSURANCE SERVICES NATIONAL, IN |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 64548 ) |
| Policy contract number | VDT960824 |
| Policy instance | 8 |
| Insurance contract or identification number | VDT960824 | | Number of Individuals Covered | 140 | | Insurance policy start date | 2017-04-01 | | Insurance policy end date | 2018-04-01 | | Total amount of commissions paid to insurance broker | USD $3,811 | | Total amount of fees paid to insurance company | USD $616 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $25,408 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,811 | | Amount paid for insurance broker fees | 616 | | Additional information about fees paid to insurance broker | SALES AND SERVICE | | Insurance broker organization code? | 3 | | Insurance broker name | USI INSURANCE SERVICES NA |
|
| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
| Policy contract number | 03292A |
| Policy instance | 10 |
| Insurance contract or identification number | 03292A | | Number of Individuals Covered | 4 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $4,380 | | Health Insurance Welfare Benefit | Yes | | Other welfare benefits provided | EVACUATION | | Welfare Benefit Premiums Paid to Carrier | USD $54,744 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,380 | | Additional information about fees paid to insurance broker | SALES AND SERVICE | | Insurance broker organization code? | 3 | | Insurance broker name | WELLS FARGO INSURANCE SERVICES MI |
|
| ACE AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 22667 ) |
| Policy contract number | GLM N10845762 |
| Policy instance | 9 |
| Insurance contract or identification number | GLM N10845762 | | Number of Individuals Covered | 73 | | Insurance policy start date | 2017-07-01 | | Insurance policy end date | 2018-07-01 | | Total amount of commissions paid to insurance broker | USD $778 | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $4,415 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $778 | | Additional information about fees paid to insurance broker | SERVICES | | Insurance broker organization code? | 3 | | Insurance broker name | USI INSURANCE SERVICES NATIONAL |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 64548 ) |
| Policy contract number | 03292A |
| Policy instance | 11 |
| Insurance contract or identification number | 03292A | | Number of Individuals Covered | 4 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $111 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $1,386 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $111 | | Additional information about fees paid to insurance broker | SALES AND SERVICE | | Insurance broker organization code? | 3 | | Insurance broker name | WELLS FARGO INSURANCE SERVICES MI |
|
| HEALTHNOW NEW YORK, INC. DBA BLUESHIELD OF NORTHEASTERN NEW YORK (National Association of Insurance Commissioners NAIC id number: 55204 ) |
| Policy contract number | 00401365 |
| Policy instance | 1 |
| Insurance contract or identification number | 00401365 | | Number of Individuals Covered | 481 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Other welfare benefits provided | POS | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 64548 ) |
| Policy contract number | OK 965553 |
| Policy instance | 2 |
| Insurance contract or identification number | OK 965553 | | Number of Individuals Covered | 268 | | Insurance policy start date | 2017-04-01 | | Insurance policy end date | 2018-04-01 | | Total amount of commissions paid to insurance broker | USD $589 | | Total amount of fees paid to insurance company | USD $141 | | Other welfare benefits provided | ACCIDENTAL DEATH | | Welfare Benefit Premiums Paid to Carrier | USD $5,894 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $589 | | Amount paid for insurance broker fees | 141 | | Additional information about fees paid to insurance broker | SALES & SERVICE | | Insurance broker organization code? | 3 | | Insurance broker name | WELLS FARGO INSURANCE SERVICES |
|
