401k Plan data: EASTER SEALS TRISTATE GROUP INSURANCE PLAN plan

EASTER SEALS TRISTATE GROUP INSURANCE PLAN 401k Plan overview

Plan Name	EASTER SEALS TRISTATE GROUP INSURANCE PLAN
Plan identification number	501

EASTER SEALS TRISTATE GROUP INSURANCE PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Life insurance Dental Vision Temporary disability (accident and sickness) Long-term disability cover Other welfare benefit cover

401k Sponsoring company profile

EASTER SEALS TRISTATE LLC has sponsored the creation of one or more 401k plans.

Company Name: EASTER SEALS TRISTATE LLC

Employer identification number (EIN): 310873433

NAIC Classification: 624310
NAIC Description: Vocational Rehabilitation Services

Form 5500 Filing Information

Submission information for form 5500 for 401k plan EASTER SEALS TRISTATE GROUP INSURANCE PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2023-01-01
501 2022-01-01
501 2021-01-01
501 2020-01-01
501 2019-01-01
501 2018-01-01 PAM GREEN PAM GREEN 2019-05-10
501 2017-01-01 PAM GREEN PAM GREEN 2018-07-10

Plan Statistics for EASTER SEALS TRISTATE GROUP INSURANCE PLAN

401k plan membership statisitcs for EASTER SEALS TRISTATE GROUP INSURANCE PLAN

Measure Date Value
2023: EASTER SEALS TRISTATE GROUP INSURANCE PLAN 2023 401k membership
Total participants, beginning-of-year 2023-01-01 156
Total number of active participants reported on line 7a of the Form 5500 2023-01-01 185
Number of retired or separated participants receiving benefits 2023-01-01 0
Number of other retired or separated participants entitled to future benefits 2023-01-01 0
Total of all active and inactive participants 2023-01-01 185
2022: EASTER SEALS TRISTATE GROUP INSURANCE PLAN 2022 401k membership
Total participants, beginning-of-year 2022-01-01 153
Total number of active participants reported on line 7a of the Form 5500 2022-01-01 156
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 2022-01-01 156
2021: EASTER SEALS TRISTATE GROUP INSURANCE PLAN 2021 401k membership
Total participants, beginning-of-year 2021-01-01 146
Total number of active participants reported on line 7a of the Form 5500 2021-01-01 153
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 2021-01-01 153
2020: EASTER SEALS TRISTATE GROUP INSURANCE PLAN 2020 401k membership
Total participants, beginning-of-year 2020-01-01 171
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 146
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 2020-01-01 146
2019: EASTER SEALS TRISTATE GROUP INSURANCE PLAN 2019 401k membership
Total participants, beginning-of-year 2019-01-01 155
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 171
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 2019-01-01 171
2018: EASTER SEALS TRISTATE GROUP INSURANCE PLAN 2018 401k membership
Total participants, beginning-of-year 2018-01-01 163
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 155
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 2018-01-01 155
2017: EASTER SEALS TRISTATE GROUP INSURANCE PLAN 2017 401k membership
Total participants, beginning-of-year 2017-01-01 163
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 163
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 2017-01-01 163

Measure	Date	Value
2023: EASTER SEALS TRISTATE GROUP INSURANCE PLAN 2023 401k membership
Total participants, beginning-of-year	2023-01-01	156
Total number of active participants reported on line 7a of the Form 5500	2023-01-01	185
Number of retired or separated participants receiving benefits	2023-01-01	0
Number of other retired or separated participants entitled to future benefits	2023-01-01	0
Total of all active and inactive participants	2023-01-01	185
2022: EASTER SEALS TRISTATE GROUP INSURANCE PLAN 2022 401k membership
Total participants, beginning-of-year	2022-01-01	153
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	156
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	156
2021: EASTER SEALS TRISTATE GROUP INSURANCE PLAN 2021 401k membership
Total participants, beginning-of-year	2021-01-01	146
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	153
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	153
2020: EASTER SEALS TRISTATE GROUP INSURANCE PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	171
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	146
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	146
2019: EASTER SEALS TRISTATE GROUP INSURANCE PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	155
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	171
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	171
2018: EASTER SEALS TRISTATE GROUP INSURANCE PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	163
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	155
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	155
2017: EASTER SEALS TRISTATE GROUP INSURANCE PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	163
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	163
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	163

Form 5500 Responses for EASTER SEALS TRISTATE GROUP INSURANCE PLAN

2023: EASTER SEALS TRISTATE GROUP INSURANCE PLAN 2023 form 5500 responses
2023-01-01	Type of plan entity	Single employer plan
2023-01-01	Plan funding arrangement – Insurance	Yes
2023-01-01	Plan benefit arrangement – Insurance	Yes
2022: EASTER SEALS TRISTATE GROUP INSURANCE PLAN 2022 form 5500 responses
2022-01-01	Type of plan entity	Single employer plan
2022-01-01	Plan funding arrangement – Insurance	Yes
2022-01-01	Plan benefit arrangement – Insurance	Yes
2021: EASTER SEALS TRISTATE GROUP INSURANCE PLAN 2021 form 5500 responses
2021-01-01	Type of plan entity	Single employer plan
2021-01-01	Plan funding arrangement – Insurance	Yes
2021-01-01	Plan benefit arrangement – Insurance	Yes
2020: EASTER SEALS TRISTATE GROUP INSURANCE PLAN 2020 form 5500 responses
2020-01-01	Type of plan entity	Single employer plan
2020-01-01	Plan funding arrangement – Insurance	Yes
2020-01-01	Plan benefit arrangement – Insurance	Yes
2019: EASTER SEALS TRISTATE GROUP INSURANCE PLAN 2019 form 5500 responses
2019-01-01	Type of plan entity	Single employer plan
2019-01-01	Plan funding arrangement – Insurance	Yes
2019-01-01	Plan benefit arrangement – Insurance	Yes
2018: EASTER SEALS TRISTATE GROUP INSURANCE PLAN 2018 form 5500 responses
2018-01-01	Type of plan entity	Single employer plan
2018-01-01	Plan funding arrangement – Insurance	Yes
2018-01-01	Plan benefit arrangement – Insurance	Yes
2017: EASTER SEALS TRISTATE GROUP INSURANCE PLAN 2017 form 5500 responses
2017-01-01	Type of plan entity	Single employer plan
2017-01-01	First time form 5500 has been submitted	Yes
2017-01-01	Plan funding arrangement – Insurance	Yes
2017-01-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

HUMANA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 73288 )

Policy contract number

404999

Policy instance

Insurance contract or identification number	404999
Number of Individuals Covered	167
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $1,662
Total amount of fees paid to insurance company	USD $92
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $15,799
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HUMANA (National Association of Insurance Commissioners NAIC id number: 95348 )

Policy contract number

404999

Policy instance

Insurance contract or identification number	404999
Number of Individuals Covered	169
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $59,787
Total amount of fees paid to insurance company	USD $15,723
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,391,492
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

GLUG0B6W7

Policy instance

Insurance contract or identification number	GLUG0B6W7
Number of Individuals Covered	278
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $3,330
Total amount of fees paid to insurance company	USD $1,059
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $22,197
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

GLTD0B6W7

Policy instance

Insurance contract or identification number	GLTD0B6W7
Number of Individuals Covered	278
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $7,925
Total amount of fees paid to insurance company	USD $2,543
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $52,835
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

GVTL0B6W7

Policy instance

Insurance contract or identification number	GVTL0B6W7
Number of Individuals Covered	91
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $4,973
Total amount of fees paid to insurance company	USD $1,941
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D VOLUNTARY
Welfare Benefit Premiums Paid to Carrier	USD $33,151
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

GUC 0B6W7

Policy instance

Insurance contract or identification number	GUC 0B6W7
Number of Individuals Covered	45
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $3,827
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $25,514
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

GUDEB6W7

Policy instance

Insurance contract or identification number	GUDEB6W7
Number of Individuals Covered	63
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $2,743
Total amount of fees paid to insurance company	USD $1,147
Other welfare benefits provided	CRITICAL ILLNESS VOLUNTARY
Welfare Benefit Premiums Paid to Carrier	USD $18,290
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

GUDH0B6W7

Policy instance

Insurance contract or identification number	GUDH0B6W7
Number of Individuals Covered	74
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $2,026
Total amount of fees paid to insurance company	USD $792
Other welfare benefits provided	ACCIDENT ONLY VOLUNTARY
Welfare Benefit Premiums Paid to Carrier	USD $13,508
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HUMANA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 73288 )

Policy contract number

404999

Policy instance

Insurance contract or identification number	404999
Number of Individuals Covered	185
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $3,281
Total amount of fees paid to insurance company	USD $404
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $72,129
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

MEDICAL MUTUAL OF OHIO (National Association of Insurance Commissioners NAIC id number: 29076 )

Policy contract number

Policy instance

Number of Individuals Covered	114
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $20,640
Total amount of fees paid to insurance company	USD $118
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,800
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $20,640
Amount paid for insurance broker fees	118
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GLUG0B6W7

Policy instance

Insurance contract or identification number	GLUG0B6W7
Number of Individuals Covered	156
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $1,985
Total amount of fees paid to insurance company	USD $1,071
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $13,231
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,658
Amount paid for insurance broker fees	803
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GLTD0B6W7

Policy instance

Insurance contract or identification number	GLTD0B6W7
Number of Individuals Covered	156
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $4,753
Total amount of fees paid to insurance company	USD $2,539
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $31,689
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,971
Amount paid for insurance broker fees	1904
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GVTL0B6W7

Policy instance

Insurance contract or identification number	GVTL0B6W7
Number of Individuals Covered	59
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $3,653
Total amount of fees paid to insurance company	USD $2,147
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D VOLUNTARY
Welfare Benefit Premiums Paid to Carrier	USD $24,353
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,036
Amount paid for insurance broker fees	1610
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GUG 0B6W7

Policy instance

Insurance contract or identification number	GUG 0B6W7
Number of Individuals Covered	156
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $8,143
Total amount of fees paid to insurance company	USD $4,356
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $54,289
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,804
Amount paid for insurance broker fees	3267
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GUDEB6W7

Policy instance

Insurance contract or identification number	GUDEB6W7
Number of Individuals Covered	42
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $2,156
Total amount of fees paid to insurance company	USD $1,357
Other welfare benefits provided	CRITICAL ILLNESS VOLUNTARY
Welfare Benefit Premiums Paid to Carrier	USD $14,377
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,818
Amount paid for insurance broker fees	1018
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GUDH0B6W7

Policy instance

Insurance contract or identification number	GUDH0B6W7
Number of Individuals Covered	49
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $1,481
Total amount of fees paid to insurance company	USD $828
Other welfare benefits provided	ACCIDENT ONLY VOLUNTARY
Welfare Benefit Premiums Paid to Carrier	USD $9,876
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,248
Amount paid for insurance broker fees	621
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3

SUPERIOR DENTAL CARE, INC. (National Association of Insurance Commissioners NAIC id number: 96280 )

Policy contract number

D9486

Policy instance

Insurance contract or identification number	D9486
Number of Individuals Covered	220
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $4,074
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 $4,074
Insurance broker organization code?	3

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

10361521001

Policy instance

Insurance contract or identification number	10361521001
Number of Individuals Covered	197
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $1,266
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $13,778
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,266
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GLTD0B6W7

Policy instance

Insurance contract or identification number	GLTD0B6W7
Number of Individuals Covered	153
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $4,367
Total amount of fees paid to insurance company	USD $2,367
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $29,114
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,367
Amount paid for insurance broker fees	1775
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GVTL0B6W7

Policy instance

Insurance contract or identification number	GVTL0B6W7
Number of Individuals Covered	58
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $3,679
Total amount of fees paid to insurance company	USD $2,172
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D VOLUNTARY
Welfare Benefit Premiums Paid to Carrier	USD $24,527
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,679
Amount paid for insurance broker fees	1629
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GUG 0B6W7

Policy instance

Insurance contract or identification number	GUG 0B6W7
Number of Individuals Covered	153
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $7,494
Total amount of fees paid to insurance company	USD $4,053
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $49,959
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,494
Amount paid for insurance broker fees	3040
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GUDEB6W7

Policy instance

Insurance contract or identification number	GUDEB6W7
Number of Individuals Covered	48
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $2,346
Total amount of fees paid to insurance company	USD $791
Other welfare benefits provided	CRITICAL ILLNESS VOLUNTARY
Welfare Benefit Premiums Paid to Carrier	USD $15,639
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,346
Amount paid for insurance broker fees	503
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GUDH0B6W7

Policy instance

Insurance contract or identification number	GUDH0B6W7
Number of Individuals Covered	49
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $1,438
Total amount of fees paid to insurance company	USD $564
Other welfare benefits provided	ACCIDENT ONLY VOLUNTARY
Welfare Benefit Premiums Paid to Carrier	USD $9,588
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,438
Amount paid for insurance broker fees	359
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GLUG0B6W7

Policy instance

Insurance contract or identification number	GLUG0B6W7
Number of Individuals Covered	152
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $1,840
Total amount of fees paid to insurance company	USD $1,000
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $12,264
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,840
Amount paid for insurance broker fees	750
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3

COMMUNITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 10345 )

Policy contract number

OH2139

Policy instance

Insurance contract or identification number	OH2139
Number of Individuals Covered	120
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $29,000
Total amount of fees paid to insurance company	USD $2,420
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,629,057
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $29,000
Amount paid for insurance broker fees	2420
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3

COMMUNITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 10345 )

Policy contract number

OH2139

Policy instance

Insurance contract or identification number	OH2139
Number of Individuals Covered	124
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $32,124
Total amount of fees paid to insurance company	USD $1,080
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,610,762
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $26,557
Amount paid for insurance broker fees	1080
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GLTD0B6W7

Policy instance

Insurance contract or identification number	GLTD0B6W7
Number of Individuals Covered	146
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $4,439
Total amount of fees paid to insurance company	USD $2,692
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $29,591
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,652
Insurance broker organization code?	3
Amount paid for insurance broker fees	2019
Additional information about fees paid to insurance broker	BROKER BONUS

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GLUG0B6W7

Policy instance

Insurance contract or identification number	GLUG0B6W7
Number of Individuals Covered	146
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $1,875
Total amount of fees paid to insurance company	USD $1,133
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $12,502
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,542
Insurance broker organization code?	3
Amount paid for insurance broker fees	850
Additional information about fees paid to insurance broker	BROKER BONUS

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GVTL0B6W7

Policy instance

Insurance contract or identification number	GVTL0B6W7
Number of Individuals Covered	61
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $4,071
Total amount of fees paid to insurance company	USD $2,351
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D VOLUNTARY
Welfare Benefit Premiums Paid to Carrier	USD $27,142
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,284
Insurance broker organization code?	3
Amount paid for insurance broker fees	1763
Additional information about fees paid to insurance broker	BROKER BONUS

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GUG 0B6W7

Policy instance

Insurance contract or identification number	GUG 0B6W7
Number of Individuals Covered	146
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $7,600
Total amount of fees paid to insurance company	USD $3,072
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $50,663
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,250
Insurance broker organization code?	3
Amount paid for insurance broker fees	1955
Additional information about fees paid to insurance broker	BONUS

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GUDEB6W7

Policy instance

Insurance contract or identification number	GUDEB6W7
Number of Individuals Covered	42
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $1,801
Total amount of fees paid to insurance company	USD $575
Other welfare benefits provided	CRITICAL ILLNESS VOLUNTARY
Welfare Benefit Premiums Paid to Carrier	USD $12,003
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,481
Insurance broker organization code?	3
Amount paid for insurance broker fees	575
Additional information about fees paid to insurance broker	BONUS

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GUDH0B6W7

Policy instance

Insurance contract or identification number	GUDH0B6W7
Number of Individuals Covered	47
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $1,394
Total amount of fees paid to insurance company	USD $411
Other welfare benefits provided	ACCIDENT ONLY VOLUNTARY
Welfare Benefit Premiums Paid to Carrier	USD $9,288
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,137
Insurance broker organization code?	3
Amount paid for insurance broker fees	411
Additional information about fees paid to insurance broker	BONUS

COMMUNITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 10345 )

Policy contract number

OH2139

Policy instance

Insurance contract or identification number	OH2139
Number of Individuals Covered	139
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $31,676
Total amount of fees paid to insurance company	USD $5,169
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,591,923
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $31,676
Amount paid for insurance broker fees	5169
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GLTD0B6W7

Policy instance

Insurance contract or identification number	GLTD0B6W7
Number of Individuals Covered	171
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $5,048
Total amount of fees paid to insurance company	USD $2,288
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $33,656
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,048
Amount paid for insurance broker fees	1961
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GVTL0B6W7

Policy instance

Insurance contract or identification number	GVTL0B6W7
Number of Individuals Covered	83
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $4,407
Total amount of fees paid to insurance company	USD $1,966
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D VOLUNTARY
Welfare Benefit Premiums Paid to Carrier	USD $29,382
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,407
Amount paid for insurance broker fees	1685
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GLUG0B6W7

Policy instance

Insurance contract or identification number	GLUG0B6W7
Number of Individuals Covered	171
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $2,124
Total amount of fees paid to insurance company	USD $963
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $14,162
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,124
Amount paid for insurance broker fees	825
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GUG 0B6W7

Policy instance

Insurance contract or identification number	GUG 0B6W7
Number of Individuals Covered	171
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $8,327
Total amount of fees paid to insurance company	USD $2,234
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $55,516
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,327
Amount paid for insurance broker fees	2234
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GVTL0B6W7

Policy instance

Insurance contract or identification number	GVTL0B6W7
Number of Individuals Covered	68
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $4,213
Total amount of fees paid to insurance company	USD $626
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D VOLUNTARY
Welfare Benefit Premiums Paid to Carrier	USD $28,088
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,213
Amount paid for insurance broker fees	487
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3

HUMANA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 73288 )

Policy contract number

774751

Policy instance

Insurance contract or identification number	774751
Number of Individuals Covered	134
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $4,389
Total amount of fees paid to insurance company	USD $1,750
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $79,523
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,389
Amount paid for insurance broker fees	1750
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3

HUMANA (National Association of Insurance Commissioners NAIC id number: 95348 )

Policy contract number

774751

Policy instance

Insurance contract or identification number	774751
Number of Individuals Covered	155
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $31,058
Total amount of fees paid to insurance company	USD $60
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,415,414
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $31,058
Amount paid for insurance broker fees	60
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GLUG0B6W7

Policy instance

Insurance contract or identification number	GLUG0B6W7
Number of Individuals Covered	180
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $2,064
Total amount of fees paid to insurance company	USD $312
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $13,757
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,064
Amount paid for insurance broker fees	243
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GLTD0B6W7

Policy instance

Insurance contract or identification number	GLTD0B6W7
Number of Individuals Covered	186
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $4,901
Total amount of fees paid to insurance company	USD $746
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $32,676
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,901
Amount paid for insurance broker fees	580
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3

HUMANA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 73288 )

Policy contract number

774751

Policy instance

Insurance contract or identification number	774751
Number of Individuals Covered	136
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $4,459
Total amount of fees paid to insurance company	USD $2,606
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $98,933
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,459
Amount paid for insurance broker fees	2606
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3
Insurance broker name	STRATEGIC EMPLOYEE BENEFIT SVCS

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GLTD0B6W7

Policy instance

Insurance contract or identification number	GLTD0B6W7
Number of Individuals Covered	197
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $2,526
Total amount of fees paid to insurance company	USD $1,325
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $16,842
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,526
Amount paid for insurance broker fees	1325
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3
Insurance broker name	STRATEGIC EMPLOYEE BENEFIT SVCS

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GLUGB6W7

Policy instance

Insurance contract or identification number	GLUGB6W7
Number of Individuals Covered	197
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $1,059
Total amount of fees paid to insurance company	USD $556
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $7,060
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,059
Amount paid for insurance broker fees	556
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3
Insurance broker name	STRATEGIC EMPLOYEE BENEFIT SVCS

METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )

Policy contract number

TM05924996

Policy instance

Insurance contract or identification number	TM05924996
Number of Individuals Covered	248
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $5,677
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $32,998
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,677
Insurance broker organization code?	3
Insurance broker name	STRATEGIC EMPLOYEE BENEFIT SVCS

HUMANA (National Association of Insurance Commissioners NAIC id number: 95348 )

Policy contract number

774751

Policy instance

Insurance contract or identification number	774751
Number of Individuals Covered	163
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $29,994
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,637,186
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $29,994
Insurance broker organization code?	3
Insurance broker name	STRATEGIC EMPLOYEE BENEFIT SVCS

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GVTL0B6W7

Policy instance

Insurance contract or identification number	GVTL0B6W7
Number of Individuals Covered	91
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $2,047
Total amount of fees paid to insurance company	USD $1,114
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D VOLUNTARY
Welfare Benefit Premiums Paid to Carrier	USD $13,649
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,047
Amount paid for insurance broker fees	1114
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3
Insurance broker name	STRATEGIC EMPLOYEE BENEFIT SVCS

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Company Name:	EASTER SEALS TRISTATE LLC
Employer identification number (EIN):	310873433
NAIC Classification:	624310
NAIC Description:	Vocational Rehabilitation Services