A & H SPORTWEAR COMPANY, INC. has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan A & H SPORTSWEAR COMPANY, INC. HEALTH AND WELFARE PLAN
401k plan membership statisitcs for A & H SPORTSWEAR COMPANY, INC. HEALTH AND WELFARE PLAN
| Measure | Date | Value |
|---|
| 2023: A & H SPORTSWEAR COMPANY, INC. HEALTH AND WELFARE PLAN 2023 401k membership |
|---|
| Total participants, beginning-of-year | 2023-03-01 | 307 |
| Total number of active participants reported on line 7a of the Form 5500 | 2023-03-01 | 332 |
| Number of retired or separated participants receiving benefits | 2023-03-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2023-03-01 | 0 |
| Total of all active and inactive participants | 2023-03-01 | 332 |
| Number of employers contributing to the scheme | 2023-03-01 | 0 |
| 2022: A & H SPORTSWEAR COMPANY, INC. HEALTH AND WELFARE PLAN 2022 401k membership |
|---|
| Total participants, beginning-of-year | 2022-03-01 | 293 |
| Total number of active participants reported on line 7a of the Form 5500 | 2022-03-01 | 307 |
| Number of retired or separated participants receiving benefits | 2022-03-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2022-03-01 | 0 |
| Total of all active and inactive participants | 2022-03-01 | 307 |
| Number of employers contributing to the scheme | 2022-03-01 | 0 |
| 2021: A & H SPORTSWEAR COMPANY, INC. HEALTH AND WELFARE PLAN 2021 401k membership |
|---|
| Total participants, beginning-of-year | 2021-03-01 | 267 |
| Total number of active participants reported on line 7a of the Form 5500 | 2021-03-01 | 293 |
| Number of retired or separated participants receiving benefits | 2021-03-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2021-03-01 | 0 |
| Total of all active and inactive participants | 2021-03-01 | 293 |
| Number of employers contributing to the scheme | 2021-03-01 | 0 |
| 2020: A & H SPORTSWEAR COMPANY, INC. HEALTH AND WELFARE PLAN 2020 401k membership |
|---|
| Total participants, beginning-of-year | 2020-03-01 | 301 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-03-01 | 267 |
| Number of retired or separated participants receiving benefits | 2020-03-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2020-03-01 | 0 |
| Total of all active and inactive participants | 2020-03-01 | 267 |
| Number of employers contributing to the scheme | 2020-03-01 | 0 |
| 2019: A & H SPORTSWEAR COMPANY, INC. HEALTH AND WELFARE PLAN 2019 401k membership |
|---|
| Total participants, beginning-of-year | 2019-03-01 | 283 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-03-01 | 301 |
| Number of retired or separated participants receiving benefits | 2019-03-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2019-03-01 | 0 |
| Total of all active and inactive participants | 2019-03-01 | 301 |
| Number of employers contributing to the scheme | 2019-03-01 | 0 |
| 2018: A & H SPORTSWEAR COMPANY, INC. HEALTH AND WELFARE PLAN 2018 401k membership |
|---|
| Total participants, beginning-of-year | 2018-03-01 | 271 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-03-01 | 283 |
| Number of retired or separated participants receiving benefits | 2018-03-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2018-03-01 | 0 |
| Total of all active and inactive participants | 2018-03-01 | 283 |
| Number of employers contributing to the scheme | 2018-03-01 | 0 |
| 2017: A & H SPORTSWEAR COMPANY, INC. HEALTH AND WELFARE PLAN 2017 401k membership |
|---|
| Total participants, beginning-of-year | 2017-03-01 | 262 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-03-01 | 271 |
| Number of retired or separated participants receiving benefits | 2017-03-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2017-03-01 | 0 |
| Total of all active and inactive participants | 2017-03-01 | 271 |
| Number of employers contributing to the scheme | 2017-03-01 | 0 |
| 2016: A & H SPORTSWEAR COMPANY, INC. HEALTH AND WELFARE PLAN 2016 401k membership |
|---|
| Total participants, beginning-of-year | 2016-03-01 | 262 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-03-01 | 271 |
| Number of retired or separated participants receiving benefits | 2016-03-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2016-03-01 | 0 |
| Total of all active and inactive participants | 2016-03-01 | 271 |
| Number of employers contributing to the scheme | 2016-03-01 | 0 |
| 2015: A & H SPORTSWEAR COMPANY, INC. HEALTH AND WELFARE PLAN 2015 401k membership |
|---|
| Total participants, beginning-of-year | 2015-03-01 | 242 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-03-01 | 253 |
| Total of all active and inactive participants | 2015-03-01 | 253 |
| 2014: A & H SPORTSWEAR COMPANY, INC. HEALTH AND WELFARE PLAN 2014 401k membership |
|---|
| Total participants, beginning-of-year | 2014-03-01 | 243 |
| Total number of active participants reported on line 7a of the Form 5500 | 2014-03-01 | 242 |
| Total of all active and inactive participants | 2014-03-01 | 242 |
| 2013: A & H SPORTSWEAR COMPANY, INC. HEALTH AND WELFARE PLAN 2013 401k membership |
|---|
| Total participants, beginning-of-year | 2013-03-01 | 193 |
| Total number of active participants reported on line 7a of the Form 5500 | 2013-03-01 | 243 |
| Total of all active and inactive participants | 2013-03-01 | 243 |
| 2012: A & H SPORTSWEAR COMPANY, INC. HEALTH AND WELFARE PLAN 2012 401k membership |
|---|
| Total participants, beginning-of-year | 2012-03-01 | 203 |
| Total number of active participants reported on line 7a of the Form 5500 | 2012-03-01 | 214 |
| Total of all active and inactive participants | 2012-03-01 | 214 |
| Total participants | 2012-03-01 | 214 |
| 2011: A & H SPORTSWEAR COMPANY, INC. HEALTH AND WELFARE PLAN 2011 401k membership |
|---|
| Total participants, beginning-of-year | 2011-03-01 | 186 |
| Total number of active participants reported on line 7a of the Form 5500 | 2011-03-01 | 203 |
| Total of all active and inactive participants | 2011-03-01 | 203 |
| 2010: A & H SPORTSWEAR COMPANY, INC. HEALTH AND WELFARE PLAN 2010 401k membership |
|---|
| Total participants, beginning-of-year | 2010-03-01 | 190 |
| Total number of active participants reported on line 7a of the Form 5500 | 2010-03-01 | 186 |
| Total of all active and inactive participants | 2010-03-01 | 186 |
| 2009: A & H SPORTSWEAR COMPANY, INC. HEALTH AND WELFARE PLAN 2009 401k membership |
|---|
| Total participants, beginning-of-year | 2009-03-01 | 157 |
| Total number of active participants reported on line 7a of the Form 5500 | 2009-03-01 | 190 |
| Total of all active and inactive participants | 2009-03-01 | 190 |
| 2008: A & H SPORTSWEAR COMPANY, INC. HEALTH AND WELFARE PLAN 2008 401k membership |
|---|
| Total participants, beginning-of-year | 2008-03-01 | 145 |
| Total number of active participants reported on line 7a of the Form 5500 | 2008-03-01 | 157 |
| Total of all active and inactive participants | 2008-03-01 | 157 |
| 2023: A & H SPORTSWEAR COMPANY, INC. HEALTH AND WELFARE PLAN 2023 form 5500 responses |
|---|
| 2023-03-01 | Type of plan entity | Multi-employer plan |
| 2023-03-01 | Plan is a collectively bargained plan | Yes |
| 2023-03-01 | Plan funding arrangement – Insurance | Yes |
| 2023-03-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2023-03-01 | Plan benefit arrangement – Insurance | Yes |
| 2023-03-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2022: A & H SPORTSWEAR COMPANY, INC. HEALTH AND WELFARE PLAN 2022 form 5500 responses |
|---|
| 2022-03-01 | Type of plan entity | Multi-employer plan |
| 2022-03-01 | Plan is a collectively bargained plan | Yes |
| 2022-03-01 | Plan funding arrangement – Insurance | Yes |
| 2022-03-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2022-03-01 | Plan benefit arrangement – Insurance | Yes |
| 2022-03-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2021: A & H SPORTSWEAR COMPANY, INC. HEALTH AND WELFARE PLAN 2021 form 5500 responses |
|---|
| 2021-03-01 | Type of plan entity | Multi-employer plan |
| 2021-03-01 | Plan is a collectively bargained plan | Yes |
| 2021-03-01 | Plan funding arrangement – Insurance | Yes |
| 2021-03-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2021-03-01 | Plan benefit arrangement – Insurance | Yes |
| 2021-03-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2020: A & H SPORTSWEAR COMPANY, INC. HEALTH AND WELFARE PLAN 2020 form 5500 responses |
|---|
| 2020-03-01 | Type of plan entity | Multi-employer plan |
| 2020-03-01 | Plan is a collectively bargained plan | Yes |
| 2020-03-01 | Plan funding arrangement – Insurance | Yes |
| 2020-03-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2020-03-01 | Plan benefit arrangement – Insurance | Yes |
| 2020-03-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2019: A & H SPORTSWEAR COMPANY, INC. HEALTH AND WELFARE PLAN 2019 form 5500 responses |
|---|
| 2019-03-01 | Type of plan entity | Multi-employer plan |
| 2019-03-01 | Plan funding arrangement – Insurance | Yes |
| 2019-03-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2019-03-01 | Plan benefit arrangement – Insurance | Yes |
| 2019-03-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2018: A & H SPORTSWEAR COMPANY, INC. HEALTH AND WELFARE PLAN 2018 form 5500 responses |
|---|
| 2018-03-01 | Type of plan entity | Multi-employer plan |
| 2018-03-01 | Plan funding arrangement – Insurance | Yes |
| 2018-03-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2018-03-01 | Plan benefit arrangement – Insurance | Yes |
| 2018-03-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2017: A & H SPORTSWEAR COMPANY, INC. HEALTH AND WELFARE PLAN 2017 form 5500 responses |
|---|
| 2017-03-01 | Type of plan entity | Multi-employer plan |
| 2017-03-01 | Plan funding arrangement – Insurance | Yes |
| 2017-03-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2017-03-01 | Plan benefit arrangement – Insurance | Yes |
| 2017-03-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2016: A & H SPORTSWEAR COMPANY, INC. HEALTH AND WELFARE PLAN 2016 form 5500 responses |
|---|
| 2016-03-01 | Type of plan entity | Multi-employer plan |
| 2016-03-01 | Plan funding arrangement – Insurance | Yes |
| 2016-03-01 | Plan benefit arrangement – Insurance | Yes |
| 2015: A & H SPORTSWEAR COMPANY, INC. HEALTH AND WELFARE PLAN 2015 form 5500 responses |
|---|
| 2015-03-01 | Type of plan entity | Single employer plan |
| 2015-03-01 | Plan funding arrangement – Insurance | Yes |
| 2015-03-01 | Plan benefit arrangement – Insurance | Yes |
| 2014: A & H SPORTSWEAR COMPANY, INC. HEALTH AND WELFARE PLAN 2014 form 5500 responses |
|---|
| 2014-03-01 | Type of plan entity | Single employer plan |
| 2014-03-01 | Plan funding arrangement – Insurance | Yes |
| 2014-03-01 | Plan benefit arrangement – Insurance | Yes |
| 2013: A & H SPORTSWEAR COMPANY, INC. HEALTH AND WELFARE PLAN 2013 form 5500 responses |
|---|
| 2013-03-01 | Type of plan entity | Single employer plan |
| 2013-03-01 | Plan funding arrangement – Insurance | Yes |
| 2013-03-01 | Plan benefit arrangement – Insurance | Yes |
| 2012: A & H SPORTSWEAR COMPANY, INC. HEALTH AND WELFARE PLAN 2012 form 5500 responses |
|---|
| 2012-03-01 | Type of plan entity | Single employer plan |
| 2012-03-01 | Submission has been amended | No |
| 2012-03-01 | This submission is the final filing | No |
| 2012-03-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2012-03-01 | Plan is a collectively bargained plan | No |
| 2012-03-01 | Plan funding arrangement – Insurance | Yes |
| 2012-03-01 | Plan benefit arrangement – Insurance | Yes |
| 2011: A & H SPORTSWEAR COMPANY, INC. HEALTH AND WELFARE PLAN 2011 form 5500 responses |
|---|
| 2011-03-01 | Type of plan entity | Single employer plan |
| 2011-03-01 | Plan funding arrangement – Insurance | Yes |
| 2011-03-01 | Plan benefit arrangement – Insurance | Yes |
| 2010: A & H SPORTSWEAR COMPANY, INC. HEALTH AND WELFARE PLAN 2010 form 5500 responses |
|---|
| 2010-03-01 | Type of plan entity | Single employer plan |
| 2010-03-01 | Plan funding arrangement – Insurance | Yes |
| 2010-03-01 | Plan benefit arrangement – Insurance | Yes |
| 2009: A & H SPORTSWEAR COMPANY, INC. HEALTH AND WELFARE PLAN 2009 form 5500 responses |
|---|
| 2009-03-01 | Type of plan entity | Single employer plan |
| 2009-03-01 | Plan funding arrangement – Insurance | Yes |
| 2009-03-01 | Plan benefit arrangement – Insurance | Yes |
| 2008: A & H SPORTSWEAR COMPANY, INC. HEALTH AND WELFARE PLAN 2008 form 5500 responses |
|---|
| 2008-03-01 | Type of plan entity | Single employer plan |
| 2008-03-01 | Plan funding arrangement – Insurance | Yes |
| 2008-03-01 | Plan benefit arrangement – Insurance | Yes |
| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65675 ) |
| Policy contract number | LIFE-0000128038 |
| Policy instance | 2 |
| Insurance contract or identification number | LIFE-0000128038 | | Number of Individuals Covered | 289 | | Insurance policy start date | 2023-03-01 | | Insurance policy end date | 2024-02-29 | | Total amount of commissions paid to insurance broker | USD $14,887 | | Total amount of fees paid to insurance company | USD $2,053 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $149,194 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| CAPITAL ADVANTAGE ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 14411 ) |
| Policy contract number | 531728 |
| Policy instance | 1 |
| Insurance contract or identification number | 531728 | | Number of Individuals Covered | 393 | | Insurance policy start date | 2023-03-01 | | Insurance policy end date | 2024-02-29 | | Total amount of commissions paid to insurance broker | USD $12,520 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65675 ) |
| Policy contract number | LTD-0000128036 |
| Policy instance | 2 |
| Insurance contract or identification number | LTD-0000128036 | | Number of Individuals Covered | 307 | | Insurance policy start date | 2022-03-01 | | Insurance policy end date | 2023-02-28 | | Total amount of commissions paid to insurance broker | USD $11,852 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $88,652 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $11,852 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| CAPITAL ADVANTAGE ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 14411 ) |
| Policy contract number | 531728 |
| Policy instance | 1 |
| Insurance contract or identification number | 531728 | | Number of Individuals Covered | 384 | | Insurance policy start date | 2022-03-01 | | Insurance policy end date | 2023-02-28 | | Total amount of commissions paid to insurance broker | USD $79,187 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | 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 $79,187 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| CAPITAL ADVANTAGE ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 14411 ) |
| Policy contract number | 531728 |
| Policy instance | 1 |
| Insurance contract or identification number | 531728 | | Number of Individuals Covered | 386 | | Insurance policy start date | 2021-03-01 | | Insurance policy end date | 2022-02-28 | | Total amount of commissions paid to insurance broker | USD $78,635 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | 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 $78,635 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GVTL01W45 |
| Policy instance | 2 |
| Insurance contract or identification number | GVTL01W45 | | Number of Individuals Covered | 293 | | Insurance policy start date | 2021-03-01 | | Insurance policy end date | 2022-02-28 | | Total amount of commissions paid to insurance broker | USD $15,806 | | Total amount of fees paid to insurance company | USD $11,448 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $149,769 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $15,806 | | Amount paid for insurance broker fees | 7632 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG01W45 |
| Policy instance | 2 |
| Insurance contract or identification number | GLUG01W45 | | Number of Individuals Covered | 267 | | Insurance policy start date | 2020-03-01 | | Insurance policy end date | 2021-02-28 | | Total amount of commissions paid to insurance broker | USD $13,058 | | Total amount of fees paid to insurance company | USD $4,136 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $115,679 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $13,058 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION |
|
| CAPITAL ADVANTAGE ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 14411 ) |
| Policy contract number | 531728 |
| Policy instance | 1 |
| Insurance contract or identification number | 531728 | | Number of Individuals Covered | 205 | | Insurance policy start date | 2020-03-01 | | Insurance policy end date | 2021-02-28 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG01W45 |
| Policy instance | 2 |
| Insurance contract or identification number | GLUG01W45 | | Number of Individuals Covered | 301 | | Insurance policy start date | 2019-03-01 | | Insurance policy end date | 2020-02-29 | | Total amount of commissions paid to insurance broker | USD $16,680 | | Total amount of fees paid to insurance company | USD $6,061 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $155,611 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $16,680 | | Amount paid for insurance broker fees | 6061 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| CAPITAL ADVANTAGE ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 14411 ) |
| Policy contract number | 531728 |
| Policy instance | 1 |
| Insurance contract or identification number | 531728 | | Number of Individuals Covered | 233 | | Insurance policy start date | 2019-03-01 | | Insurance policy end date | 2020-02-29 | | Total amount of commissions paid to insurance broker | USD $71,617 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | 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 $71,617 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| HIGHMARK BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 54771 ) |
| Policy contract number | 02550307 |
| Policy instance | 1 |
| Insurance contract or identification number | 02550307 | | Number of Individuals Covered | 370 | | Insurance policy start date | 2018-03-01 | | Insurance policy end date | 2019-02-28 | | Total amount of commissions paid to insurance broker | USD $78,834 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $2,723,219 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $78,834 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG01W45 |
| Policy instance | 2 |
| Insurance contract or identification number | GLUG01W45 | | Number of Individuals Covered | 283 | | Insurance policy start date | 2018-03-01 | | Insurance policy end date | 2019-02-28 | | Total amount of commissions paid to insurance broker | USD $15,008 | | Total amount of fees paid to insurance company | USD $1,869 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $147,847 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $15,008 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG01W45 |
| Policy instance | 2 |
| Insurance contract or identification number | GLUG01W45 | | Number of Individuals Covered | 271 | | Insurance policy start date | 2017-03-01 | | Insurance policy end date | 2018-02-28 | | Total amount of commissions paid to insurance broker | USD $16,159 | | Total amount of fees paid to insurance company | USD $7,920 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $144,916 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $16,159 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION |
|
| HIGHMARK BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 54771 ) |
| Policy contract number | 02550307 |
| Policy instance | 1 |
| Insurance contract or identification number | 02550307 | | Number of Individuals Covered | 362 | | Insurance policy start date | 2017-03-01 | | Insurance policy end date | 2018-02-28 | | Total amount of commissions paid to insurance broker | USD $152,859 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $2,808,635 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $152,859 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 71412 ) |
| Policy contract number | GMTD01W45 |
| Policy instance | 2 |
| Insurance contract or identification number | GMTD01W45 | | Number of Individuals Covered | 247 | | Insurance policy start date | 2016-03-01 | | Insurance policy end date | 2017-02-28 | | Total amount of commissions paid to insurance broker | USD $4,696 | | Total amount of fees paid to insurance company | USD $0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $69,685 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,696 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG01W45 |
| Policy instance | 3 |
| Insurance contract or identification number | GLUG01W45 | | Number of Individuals Covered | 262 | | Insurance policy start date | 2016-03-01 | | Insurance policy end date | 2017-02-28 | | Total amount of commissions paid to insurance broker | USD $9,370 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $62,467 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $9,370 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| HIGHMARK BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 54771 ) |
| Policy contract number | 02550307 |
| Policy instance | 1 |
| Insurance contract or identification number | 02550307 | | Number of Individuals Covered | 348 | | Insurance policy start date | 2016-03-01 | | Insurance policy end date | 2017-02-28 | | Total amount of commissions paid to insurance broker | USD $71,417 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $2,574,625 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $71,417 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 71412 ) |
| Policy contract number | G001W45 |
| Policy instance | 1 |
| Insurance contract or identification number | G001W45 | | Number of Individuals Covered | 253 | | Insurance policy start date | 2016-03-01 | | Insurance policy end date | 2016-02-29 | | Total amount of commissions paid to insurance broker | USD $4,618 | | Total amount of fees paid to insurance company | USD $0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $71,329 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,618 | | Insurance broker organization code? | 3 | | Insurance broker name | AMERICAN INSURANCE ADMINISTRATORS |
|
| HIGHMARK BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 54771 ) |
| Policy contract number | 02550307 |
| Policy instance | 2 |
| Insurance contract or identification number | 02550307 | | Number of Individuals Covered | 203 | | Insurance policy start date | 2015-03-01 | | Insurance policy end date | 2016-02-29 | | Total amount of commissions paid to insurance broker | USD $78,616 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $2,897,184 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $78,616 | | Insurance broker organization code? | 3 | | Insurance broker name | AMERICAN INSURANCE ADMINISTRATORS |
|
| HIGHMARK BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 54771 ) |
| Policy contract number | 02895661 |
| Policy instance | 4 |
| Insurance contract or identification number | 02895661 | | Number of Individuals Covered | 399 | | Insurance policy start date | 2014-03-01 | | Insurance policy end date | 2015-02-28 | | Total amount of commissions paid to insurance broker | USD $295 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $20,371 | | 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 | | Insurance broker organization code? | 3 | | Insurance broker name | AMERICAN INSURANCE ADMINISTRATORS |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 71412 ) |
| Policy contract number | G001W45 |
| Policy instance | 3 |
| Insurance contract or identification number | G001W45 | | Number of Individuals Covered | 242 | | Insurance policy start date | 2013-10-01 | | Insurance policy end date | 2014-10-01 | | Total amount of commissions paid to insurance broker | USD $4,632 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $63,156 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,632 | | Insurance broker organization code? | 3 | | Insurance broker name | AMERICAN INSURANCE ADMINISTRATORS |
|
| KEYSTONE HEALTH PLAN CENTRAL (National Association of Insurance Commissioners NAIC id number: 95199 ) |
| Policy contract number | 00508101 |
| Policy instance | 1 |
| Insurance contract or identification number | 00508101 | | Number of Individuals Covered | 18 | | Insurance policy start date | 2014-03-01 | | Insurance policy end date | 2015-02-28 | | Total amount of commissions paid to insurance broker | USD $5,350 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 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 $5,350 | | Insurance broker organization code? | 3 | | Insurance broker name | AMERICAN INSURANCE ADMINISTRATORS |
|
| CAPITAL ADVANTAGE ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 14411 ) |
| Policy contract number | 00508101 |
| Policy instance | 2 |
| Insurance contract or identification number | 00508101 | | Number of Individuals Covered | 230 | | Insurance policy start date | 2014-03-01 | | Insurance policy end date | 2015-02-28 | | Total amount of commissions paid to insurance broker | USD $64,801 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | 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 $64,801 | | Insurance broker organization code? | 3 | | Insurance broker name | AMERICAN INSURANCE ADMINISTRATORS |
|
| HIGHMARK BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 54771 ) |
| Policy contract number | 02895661 |
| Policy instance | 4 |
| Insurance contract or identification number | 02895661 | | Number of Individuals Covered | 381 | | Insurance policy start date | 2013-03-01 | | Insurance policy end date | 2014-02-28 | | Total amount of commissions paid to insurance broker | USD $327 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $21,778 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $327 | | Insurance broker organization code? | 3 | | Insurance broker name | AMERICAN INSURANCE ADMINISTRATORS |
|
| KEYSTONE HEALTH PLAN CENTRAL (National Association of Insurance Commissioners NAIC id number: 95199 ) |
| Policy contract number | 00508101 |
| Policy instance | 1 |
| Insurance contract or identification number | 00508101 | | Number of Individuals Covered | 18 | | Insurance policy start date | 2013-03-01 | | Insurance policy end date | 2014-02-28 | | Total amount of commissions paid to insurance broker | USD $6,055 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 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 $6,055 | | Insurance broker organization code? | 3 | | Insurance broker name | AMERICAN INSURANCE ADMINISTRATORS |
|
| CAPITAL ADVANTAGE ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 14411 ) |
| Policy contract number | 00508101 |
| Policy instance | 2 |
| Insurance contract or identification number | 00508101 | | Number of Individuals Covered | 214 | | Insurance policy start date | 2013-03-01 | | Insurance policy end date | 2014-02-28 | | Total amount of commissions paid to insurance broker | USD $62,415 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | 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 $62,415 | | Insurance broker organization code? | 3 | | Insurance broker name | AMERICAN INSURANCE ADMINISTRATORS |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 71412 ) |
| Policy contract number | G001W45 |
| Policy instance | 3 |
| Insurance contract or identification number | G001W45 | | Number of Individuals Covered | 243 | | Insurance policy start date | 2012-10-01 | | Insurance policy end date | 2013-10-01 | | Total amount of commissions paid to insurance broker | USD $4,842 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $84,226 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,842 | | Insurance broker organization code? | 3 | | Insurance broker name | EDWIN G REHRIG |
|
| CAPITAL ADVANTAGE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 41203 ) |
| Policy contract number | 00508101 |
| Policy instance | 2 |
| Insurance contract or identification number | 00508101 | | Number of Individuals Covered | 201 | | Insurance policy start date | 2012-03-01 | | Insurance policy end date | 2013-02-28 | | Total amount of commissions paid to insurance broker | USD $57,470 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Commission paid to Insurance Broker | USD $57,470 | | Insurance broker organization code? | 3 | | Insurance broker name | AMERICAN INSURANCE ADMINISTRATORS |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 71412 ) |
| Policy contract number | G0001W45 |
| Policy instance | 3 |
| Insurance contract or identification number | G0001W45 | | Number of Individuals Covered | 214 | | Insurance policy start date | 2011-10-01 | | Insurance policy end date | 2012-10-01 | | Total amount of commissions paid to insurance broker | USD $4,784 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $78,353 | | Commission paid to Insurance Broker | USD $4,784 | | Insurance broker organization code? | 3 | | Insurance broker name | EDWIN G REHRIG |
|
| HIGHMARK BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 54771 ) |
| Policy contract number | 02899971 |
| Policy instance | 4 |
| Insurance contract or identification number | 02899971 | | Number of Individuals Covered | 376 | | Insurance policy start date | 2012-03-01 | | Insurance policy end date | 2013-02-28 | | Total amount of commissions paid to insurance broker | USD $264 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $17,604 | | Commission paid to Insurance Broker | USD $264 | | Insurance broker organization code? | 3 | | Insurance broker name | AMERICAN INSURANCE ADMINISTRATORS |
|
| KEYSTONE HEALTH PLAN CENTRAL (National Association of Insurance Commissioners NAIC id number: 95199 ) |
| Policy contract number | 00508101 |
| Policy instance | 1 |
| Insurance contract or identification number | 00508101 | | Number of Individuals Covered | 19 | | Insurance policy start date | 2012-03-01 | | Insurance policy end date | 2013-02-28 | | Total amount of commissions paid to insurance broker | USD $4,500 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Commission paid to Insurance Broker | USD $4,500 | | Insurance broker organization code? | 3 | | Insurance broker name | AMERICAN INSURANCE ADMINISTRATORS |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 71412 ) |
| Policy contract number | G001W45 |
| Policy instance | 3 |
| Insurance contract or identification number | G001W45 | | Number of Individuals Covered | 203 | | Insurance policy start date | 2010-10-01 | | Insurance policy end date | 2011-10-01 | | Total amount of commissions paid to insurance broker | USD $4,724 | | Total amount of fees paid to insurance company | USD $0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $72,375 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,724 | | Insurance broker organization code? | 3 | | Insurance broker name | EDWIN G REHRIG |
|
| KEYSTONE HEALTH PLAN CENTRAL (National Association of Insurance Commissioners NAIC id number: 95199 ) |
| Policy contract number | 00508101 |
| Policy instance | 1 |
| Insurance contract or identification number | 00508101 | | Number of Individuals Covered | 14 | | Insurance policy start date | 2011-03-01 | | Insurance policy end date | 2012-02-29 | | Total amount of commissions paid to insurance broker | USD $3,125 | | 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 $3,125 | | Insurance broker organization code? | 3 | | Insurance broker name | AMERICAN INSURANCE ADMINISTRATORS |
|
| CAPITAL ADVANTAGE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 41203 ) |
| Policy contract number | 00508101 |
| Policy instance | 2 |
| Insurance contract or identification number | 00508101 | | Number of Individuals Covered | 188 | | Insurance policy start date | 2011-03-01 | | Insurance policy end date | 2012-02-29 | | Total amount of commissions paid to insurance broker | USD $84,706 | | Total amount of fees paid to insurance company | USD $0 | | 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 $84,706 | | Insurance broker organization code? | 3 | | Insurance broker name | AMERICAN INSURANCE ADMINISTRATORS |
|
| HIGHMARK BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 54771 ) |
| Policy contract number | 02895661 |
| Policy instance | 4 |
| Insurance contract or identification number | 02895661 | | Number of Individuals Covered | 359 | | Insurance policy start date | 2011-03-01 | | Insurance policy end date | 2012-02-29 | | Total amount of commissions paid to insurance broker | USD $253 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $16,882 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $253 | | Insurance broker organization code? | 3 | | Insurance broker name | AMERICAN INSURANCE ADMINISTRATORS |
|
| UNITED CONCORDIA LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62294 ) |
| Policy contract number | 883431 |
| Policy instance | 5 |
| Insurance contract or identification number | 883431 | | Number of Individuals Covered | 296 | | Insurance policy start date | 2010-08-01 | | Insurance policy end date | 2011-07-31 | | Total amount of commissions paid to insurance broker | USD $4,364 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $72,419 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,364 | | Insurance broker organization code? | 3 | | Insurance broker name | AMERICAN INSURANCE ADMINISTRATORS |
|
| HIGHMARK BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 54771 ) |
| Policy contract number | 02899971 |
| Policy instance | 4 |
| Insurance contract or identification number | 02899971 | | Number of Individuals Covered | 338 | | Insurance policy start date | 2010-03-01 | | Insurance policy end date | 2011-02-28 | | Total amount of commissions paid to insurance broker | USD $238 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $15,834 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $238 | | Insurance broker organization code? | 3 | | Insurance broker name | AMERICAN INSURANCE ADMINISTRATORS |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 71412 ) |
| Policy contract number | G001W45 |
| Policy instance | 3 |
| Insurance contract or identification number | G001W45 | | Number of Individuals Covered | 186 | | Insurance policy start date | 2009-10-01 | | Insurance policy end date | 2010-10-01 | | Total amount of commissions paid to insurance broker | USD $4,660 | | Total amount of fees paid to insurance company | USD $0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $65,983 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,660 | | Insurance broker organization code? | 3 | | Insurance broker name | EDWIN G REHRIG |
|
| CAPITAL ADVANTAGE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 41203 ) |
| Policy contract number | 00508101 |
| Policy instance | 2 |
| Insurance contract or identification number | 00508101 | | Number of Individuals Covered | 177 | | Insurance policy start date | 2010-03-01 | | Insurance policy end date | 2011-02-28 | | Total amount of commissions paid to insurance broker | USD $101,950 | | 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 $101,950 | | Insurance broker organization code? | 3 | | Insurance broker name | AMERICAN INSURANCE ADMINISTRATORS |
|
| KEYSTONE HEALTH PLAN CENTRAL (National Association of Insurance Commissioners NAIC id number: 95199 ) |
| Policy contract number | 00508101 |
| Policy instance | 1 |
| Insurance contract or identification number | 00508101 | | Number of Individuals Covered | 9 | | Insurance policy start date | 2010-03-01 | | Insurance policy end date | 2011-02-28 | | Total amount of commissions paid to insurance broker | USD $2,525 | | 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 $2,525 | | Insurance broker organization code? | 3 | | Insurance broker name | AMERICAN INSURANCE ADMINISTRATORS |
|
| UNITED CONCORDIA LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62294 ) |
| Policy contract number | 883431 |
| Policy instance | 5 |
| Insurance contract or identification number | 883431 | | Number of Individuals Covered | 264 | | Insurance policy start date | 2009-08-01 | | Insurance policy end date | 2010-07-31 | | Total amount of commissions paid to insurance broker | USD $3,962 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $66,169 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,962 | | Insurance broker organization code? | 3 | | Insurance broker name | AMERICAN INSURANCE ADMINISTRATORS |
|
| KEYSTONE HEALTH PLAN CENTRAL (National Association of Insurance Commissioners NAIC id number: 95199 ) |
| Policy contract number | 00508101 |
| Policy instance | 1 |
| Insurance contract or identification number | 00508101 | | Number of Individuals Covered | 10 | | Insurance policy start date | 2009-03-01 | | Insurance policy end date | 2010-02-28 | | Total amount of commissions paid to insurance broker | USD $2,977 | | 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 $2,600 | | Insurance broker organization code? | 3 | | Insurance broker name | DANIEL MCLAUGHLIN |
|
| CAPITAL ADVANTAGE ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 41203 ) |
| Policy contract number | 00508101 |
| Policy instance | 2 |
| Insurance contract or identification number | 00508101 | | Number of Individuals Covered | 167 | | Insurance policy start date | 2009-03-01 | | Insurance policy end date | 2010-02-28 | | Total amount of commissions paid to insurance broker | USD $47,091 | | 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 $39,675 | | Insurance broker organization code? | 3 | | Insurance broker name | DANIEL MCLAUGHLIN |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 71412 ) |
| Policy contract number | G001W45 |
| Policy instance | 3 |
| Insurance contract or identification number | G001W45 | | Number of Individuals Covered | 190 | | Insurance policy start date | 2008-10-01 | | Insurance policy end date | 2009-10-01 | | Total amount of commissions paid to insurance broker | USD $4,635 | | Total amount of fees paid to insurance company | USD $0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $63,519 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,635 | | Insurance broker organization code? | 3 | | Insurance broker name | EDWIN G REHRIG |
|
| HIGHMARK BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 54771 ) |
| Policy contract number | 02507755 |
| Policy instance | 4 |
| Insurance contract or identification number | 02507755 | | Number of Individuals Covered | 306 | | Insurance policy start date | 2009-03-01 | | Insurance policy end date | 2010-02-28 | | Total amount of commissions paid to insurance broker | USD $229 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $15,290 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $229 | | Insurance broker organization code? | 3 | | Insurance broker name | HILB, ROGAL & HAMILTON CO. |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 00 385983 |
| Policy instance | 5 |
| Insurance contract or identification number | 00 385983 | | Number of Individuals Covered | 144 | | Insurance policy start date | 2008-09-01 | | Insurance policy end date | 2009-08-31 | | Total amount of commissions paid to insurance broker | USD $5,042 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $81,681 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,836 | | Insurance broker organization code? | 3 | | Insurance broker name | AMERICAN INSURANCE ADMINISTRATORS |
|
| HIGHMARK BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 54771 ) |
| Policy contract number | 02550307 |
| Policy instance | 3 |
| Insurance contract or identification number | 02550307 | | Number of Individuals Covered | 300 | | Insurance policy start date | 2008-03-01 | | Insurance policy end date | 2009-02-28 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $14,493 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| CAPITAL ADVANTAGE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 41203 ) |
| Policy contract number | 00508101 |
| Policy instance | 2 |
| Insurance contract or identification number | 00508101 | | Number of Individuals Covered | 157 | | Insurance policy start date | 2008-03-01 | | Insurance policy end date | 2009-02-28 | | Total amount of commissions paid to insurance broker | USD $44,709 | | 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 $44,709 | | Insurance broker organization code? | 3 | | Insurance broker name | DANIEL MCLAUGHLIN |
|
| KEYSTONE HEALTH PLAN CENTRAL (National Association of Insurance Commissioners NAIC id number: 95199 ) |
| Policy contract number | 00508101 |
| Policy instance | 1 |
| Insurance contract or identification number | 00508101 | | Number of Individuals Covered | 12 | | Insurance policy start date | 2008-03-01 | | Insurance policy end date | 2009-02-28 | | Total amount of commissions paid to insurance broker | USD $971 | | 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 $971 | | Insurance broker organization code? | 3 | | Insurance broker name | DANIEL MCLAUGHLIN |
|
