DELTA DENTAL OF WISCONSIN, INC. has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan DELTA DENTAL OF WISCONSIN, INC. EMPLOYEE
401k plan membership statisitcs for DELTA DENTAL OF WISCONSIN, INC. EMPLOYEE
| Measure | Date | Value |
|---|
| 2023: DELTA DENTAL OF WISCONSIN, INC. EMPLOYEE 2023 401k membership |
|---|
| Total participants, beginning-of-year | 2023-03-01 | 353 |
| Total number of active participants reported on line 7a of the Form 5500 | 2023-03-01 | 366 |
| Number of retired or separated participants receiving benefits | 2023-03-01 | 2 |
| 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 | 368 |
| 2022: DELTA DENTAL OF WISCONSIN, INC. EMPLOYEE 2022 401k membership |
|---|
| Total participants, beginning-of-year | 2022-03-01 | 312 |
| Total number of active participants reported on line 7a of the Form 5500 | 2022-03-01 | 348 |
| Number of retired or separated participants receiving benefits | 2022-03-01 | 5 |
| 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 | 353 |
| 2021: DELTA DENTAL OF WISCONSIN, INC. EMPLOYEE 2021 401k membership |
|---|
| Total participants, beginning-of-year | 2021-03-01 | 292 |
| Total number of active participants reported on line 7a of the Form 5500 | 2021-03-01 | 309 |
| Number of retired or separated participants receiving benefits | 2021-03-01 | 3 |
| Total of all active and inactive participants | 2021-03-01 | 312 |
| 2020: DELTA DENTAL OF WISCONSIN, INC. EMPLOYEE 2020 401k membership |
|---|
| Total participants, beginning-of-year | 2020-03-01 | 289 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-03-01 | 297 |
| Number of retired or separated participants receiving benefits | 2020-03-01 | 2 |
| Total of all active and inactive participants | 2020-03-01 | 299 |
| Total participants | 2020-03-01 | 299 |
| 2019: DELTA DENTAL OF WISCONSIN, INC. EMPLOYEE 2019 401k membership |
|---|
| Total participants, beginning-of-year | 2019-03-01 | 348 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-03-01 | 286 |
| Number of retired or separated participants receiving benefits | 2019-03-01 | 1 |
| Total of all active and inactive participants | 2019-03-01 | 287 |
| Total participants | 2019-03-01 | 287 |
| 2018: DELTA DENTAL OF WISCONSIN, INC. EMPLOYEE 2018 401k membership |
|---|
| Total participants, beginning-of-year | 2018-03-01 | 312 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-03-01 | 344 |
| Number of retired or separated participants receiving benefits | 2018-03-01 | 2 |
| Total of all active and inactive participants | 2018-03-01 | 346 |
| Total participants, beginning-of-year | 2018-01-01 | 120 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-01-01 | 125 |
| Total of all active and inactive participants | 2018-01-01 | 125 |
| Total participants | 2018-01-01 | 125 |
| 2017: DELTA DENTAL OF WISCONSIN, INC. EMPLOYEE 2017 401k membership |
|---|
| Total participants, beginning-of-year | 2017-03-01 | 265 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-03-01 | 287 |
| 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 | 287 |
| 2016: DELTA DENTAL OF WISCONSIN, INC. EMPLOYEE 2016 401k membership |
|---|
| Total participants, beginning-of-year | 2016-03-01 | 271 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-03-01 | 265 |
| Number of retired or separated participants receiving benefits | 2016-03-01 | 3 |
| 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 | 268 |
| 2015: DELTA DENTAL OF WISCONSIN, INC. EMPLOYEE 2015 401k membership |
|---|
| Total participants, beginning-of-year | 2015-03-01 | 226 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-03-01 | 271 |
| Number of retired or separated participants receiving benefits | 2015-03-01 | 2 |
| Number of other retired or separated participants entitled to future benefits | 2015-03-01 | 0 |
| Total of all active and inactive participants | 2015-03-01 | 273 |
| 2014: DELTA DENTAL OF WISCONSIN, INC. EMPLOYEE 2014 401k membership |
|---|
| Total participants, beginning-of-year | 2014-03-01 | 214 |
| Total number of active participants reported on line 7a of the Form 5500 | 2014-03-01 | 226 |
| Number of retired or separated participants receiving benefits | 2014-03-01 | 3 |
| Number of other retired or separated participants entitled to future benefits | 2014-03-01 | 0 |
| Total of all active and inactive participants | 2014-03-01 | 229 |
| 2013: DELTA DENTAL OF WISCONSIN, INC. EMPLOYEE 2013 401k membership |
|---|
| Total participants, beginning-of-year | 2013-03-01 | 196 |
| Total number of active participants reported on line 7a of the Form 5500 | 2013-03-01 | 214 |
| Number of retired or separated participants receiving benefits | 2013-03-01 | 1 |
| Number of other retired or separated participants entitled to future benefits | 2013-03-01 | 0 |
| Total of all active and inactive participants | 2013-03-01 | 215 |
| 2012: DELTA DENTAL OF WISCONSIN, INC. EMPLOYEE 2012 401k membership |
|---|
| Total participants, beginning-of-year | 2012-03-01 | 172 |
| Total number of active participants reported on line 7a of the Form 5500 | 2012-03-01 | 196 |
| Number of retired or separated participants receiving benefits | 2012-03-01 | 1 |
| Number of other retired or separated participants entitled to future benefits | 2012-03-01 | 0 |
| Total of all active and inactive participants | 2012-03-01 | 197 |
| 2011: DELTA DENTAL OF WISCONSIN, INC. EMPLOYEE 2011 401k membership |
|---|
| Total participants, beginning-of-year | 2011-03-01 | 164 |
| Total number of active participants reported on line 7a of the Form 5500 | 2011-03-01 | 172 |
| Number of retired or separated participants receiving benefits | 2011-03-01 | 2 |
| Number of other retired or separated participants entitled to future benefits | 2011-03-01 | 0 |
| Total of all active and inactive participants | 2011-03-01 | 174 |
| 2009: DELTA DENTAL OF WISCONSIN, INC. EMPLOYEE 2009 401k membership |
|---|
| Total participants, beginning-of-year | 2009-03-01 | 159 |
| Total number of active participants reported on line 7a of the Form 5500 | 2009-03-01 | 155 |
| Number of retired or separated participants receiving benefits | 2009-03-01 | 1 |
| Number of other retired or separated participants entitled to future benefits | 2009-03-01 | 0 |
| Total of all active and inactive participants | 2009-03-01 | 156 |
| 2023: DELTA DENTAL OF WISCONSIN, INC. EMPLOYEE 2023 form 5500 responses |
|---|
| 2023-03-01 | Type of plan entity | Single employer plan |
| 2023-03-01 | Submission has been amended | No |
| 2023-03-01 | This submission is the final filing | No |
| 2023-03-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2023-03-01 | Plan is a collectively bargained plan | No |
| 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: DELTA DENTAL OF WISCONSIN, INC. EMPLOYEE 2022 form 5500 responses |
|---|
| 2022-03-01 | Type of plan entity | Single employer plan |
| 2022-03-01 | Submission has been amended | No |
| 2022-03-01 | This submission is the final filing | No |
| 2022-03-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2022-03-01 | Plan is a collectively bargained plan | No |
| 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: DELTA DENTAL OF WISCONSIN, INC. EMPLOYEE 2021 form 5500 responses |
|---|
| 2021-03-01 | Type of plan entity | Single employer plan |
| 2021-03-01 | Submission has been amended | No |
| 2021-03-01 | This submission is the final filing | No |
| 2021-03-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2021-03-01 | Plan is a collectively bargained plan | No |
| 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: DELTA DENTAL OF WISCONSIN, INC. EMPLOYEE 2020 form 5500 responses |
|---|
| 2020-03-01 | Type of plan entity | Single employer plan |
| 2020-03-01 | Submission has been amended | No |
| 2020-03-01 | This submission is the final filing | No |
| 2020-03-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2020-03-01 | Plan is a collectively bargained plan | No |
| 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: DELTA DENTAL OF WISCONSIN, INC. EMPLOYEE 2019 form 5500 responses |
|---|
| 2019-03-01 | Type of plan entity | Single employer plan |
| 2019-03-01 | Submission has been amended | No |
| 2019-03-01 | This submission is the final filing | No |
| 2019-03-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2019-03-01 | Plan is a collectively bargained plan | No |
| 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: DELTA DENTAL OF WISCONSIN, INC. EMPLOYEE 2018 form 5500 responses |
|---|
| 2018-03-01 | Type of plan entity | Single employer plan |
| 2018-03-01 | Submission has been amended | No |
| 2018-03-01 | This submission is the final filing | No |
| 2018-03-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2018-03-01 | Plan is a collectively bargained plan | No |
| 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 |
| 2018-01-01 | Type of plan entity | Single employer plan |
| 2018-01-01 | First time form 5500 has been submitted | Yes |
| 2018-01-01 | Submission has been amended | No |
| 2018-01-01 | This submission is the final filing | No |
| 2018-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2018-01-01 | Plan is a collectively bargained plan | No |
| 2018-01-01 | Plan funding arrangement – Insurance | Yes |
| 2018-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2017: DELTA DENTAL OF WISCONSIN, INC. EMPLOYEE 2017 form 5500 responses |
|---|
| 2017-03-01 | Type of plan entity | Single employer plan |
| 2017-03-01 | Submission has been amended | No |
| 2017-03-01 | This submission is the final filing | No |
| 2017-03-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2017-03-01 | Plan is a collectively bargained plan | No |
| 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: DELTA DENTAL OF WISCONSIN, INC. EMPLOYEE 2016 form 5500 responses |
|---|
| 2016-03-01 | Type of plan entity | Single employer plan |
| 2016-03-01 | Submission has been amended | No |
| 2016-03-01 | This submission is the final filing | No |
| 2016-03-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2016-03-01 | Plan is a collectively bargained plan | No |
| 2016-03-01 | Plan funding arrangement – Insurance | Yes |
| 2016-03-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2016-03-01 | Plan benefit arrangement – Insurance | Yes |
| 2016-03-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2015: DELTA DENTAL OF WISCONSIN, INC. EMPLOYEE 2015 form 5500 responses |
|---|
| 2015-03-01 | Type of plan entity | Single employer plan |
| 2015-03-01 | Submission has been amended | No |
| 2015-03-01 | This submission is the final filing | No |
| 2015-03-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2015-03-01 | Plan is a collectively bargained plan | No |
| 2015-03-01 | Plan funding arrangement – Insurance | Yes |
| 2015-03-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2015-03-01 | Plan benefit arrangement – Insurance | Yes |
| 2015-03-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2014: DELTA DENTAL OF WISCONSIN, INC. EMPLOYEE 2014 form 5500 responses |
|---|
| 2014-03-01 | Type of plan entity | Single employer plan |
| 2014-03-01 | Submission has been amended | No |
| 2014-03-01 | This submission is the final filing | No |
| 2014-03-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2014-03-01 | Plan is a collectively bargained plan | No |
| 2014-03-01 | Plan funding arrangement – Insurance | Yes |
| 2014-03-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2014-03-01 | Plan benefit arrangement – Insurance | Yes |
| 2014-03-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2013: DELTA DENTAL OF WISCONSIN, INC. EMPLOYEE 2013 form 5500 responses |
|---|
| 2013-03-01 | Type of plan entity | Single employer plan |
| 2013-03-01 | Submission has been amended | No |
| 2013-03-01 | This submission is the final filing | No |
| 2013-03-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2013-03-01 | Plan is a collectively bargained plan | No |
| 2013-03-01 | Plan funding arrangement – Insurance | Yes |
| 2013-03-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2013-03-01 | Plan benefit arrangement – Insurance | Yes |
| 2013-03-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2012: DELTA DENTAL OF WISCONSIN, INC. EMPLOYEE 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 funding arrangement – General assets of the sponsor | Yes |
| 2012-03-01 | Plan benefit arrangement – Insurance | Yes |
| 2012-03-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2011: DELTA DENTAL OF WISCONSIN, INC. EMPLOYEE 2011 form 5500 responses |
|---|
| 2011-03-01 | Type of plan entity | Single employer plan |
| 2011-03-01 | Submission has been amended | No |
| 2011-03-01 | This submission is the final filing | No |
| 2011-03-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2011-03-01 | Plan is a collectively bargained plan | No |
| 2011-03-01 | Plan funding arrangement – Insurance | Yes |
| 2011-03-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2011-03-01 | Plan benefit arrangement – Insurance | Yes |
| 2011-03-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2009: DELTA DENTAL OF WISCONSIN, INC. EMPLOYEE 2009 form 5500 responses |
|---|
| 2009-03-01 | Type of plan entity | Single employer plan |
| 2009-03-01 | Submission has been amended | No |
| 2009-03-01 | This submission is the final filing | No |
| 2009-03-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2009-03-01 | Plan is a collectively bargained plan | No |
| 2009-03-01 | Plan funding arrangement – Insurance | Yes |
| 2009-03-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2009-03-01 | Plan benefit arrangement – Insurance | Yes |
| 2009-03-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | FLI0960327 |
| Policy instance | 5 |
| Insurance contract or identification number | FLI0960327 | | Insurance policy start date | 2023-01-01 | | Insurance policy end date | 2023-12-31 | | Total amount of commissions paid to insurance broker | USD $8,192 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $123,405 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| WYSSTA INSURANCE COMPANY INC. (National Association of Insurance Commissioners NAIC id number: 12352 ) |
| Policy contract number | 40179 |
| Policy instance | 4 |
| Insurance contract or identification number | 40179 | | Number of Individuals Covered | 272 | | Insurance policy start date | 2023-03-01 | | Insurance policy end date | 2024-02-29 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $54,125 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
| Policy contract number | ETB013763 |
| Policy instance | 3 |
| Insurance contract or identification number | ETB013763 | | Insurance policy start date | 2023-03-01 | | Insurance policy end date | 2024-02-28 | | Total amount of commissions paid to insurance broker | USD $170 | | Total amount of fees paid to insurance company | USD $29 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | BUSINESS TRAVEL ACCIDENT | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $1,135 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | OK0971602 |
| Policy instance | 2 |
| Insurance contract or identification number | OK0971602 | | Insurance policy start date | 2023-01-01 | | Insurance policy end date | 2023-12-31 | | Total amount of commissions paid to insurance broker | USD $1,052 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | AD&D | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $10,520 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | LK0966746 |
| Policy instance | 1 |
| Insurance contract or identification number | LK0966746 | | Insurance policy start date | 2023-01-01 | | Insurance policy end date | 2023-12-31 | | Total amount of commissions paid to insurance broker | USD $6,040 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | 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 $59,319 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GVTL0BDLQ |
| Policy instance | 1 |
| Insurance contract or identification number | GVTL0BDLQ | | Number of Individuals Covered | 225 | | Insurance policy start date | 2022-03-01 | | Insurance policy end date | 2023-01-01 | | Total amount of commissions paid to insurance broker | USD $12,293 | | Total amount of fees paid to insurance company | USD $6,887 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $70,247 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $12,293 | | Amount paid for insurance broker fees | 6887 | | 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 | GLTD0BDLQ |
| Policy instance | 2 |
| Insurance contract or identification number | GLTD0BDLQ | | Number of Individuals Covered | 329 | | Insurance policy start date | 2022-03-01 | | Insurance policy end date | 2023-01-01 | | Total amount of commissions paid to insurance broker | USD $11,781 | | Total amount of fees paid to insurance company | USD $5,942 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $67,319 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $11,781 | | Amount paid for insurance broker fees | 5942 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| WYSSTA INSURANCE COMPANY INC. (National Association of Insurance Commissioners NAIC id number: 12352 ) |
| Policy contract number | 40179 |
| Policy instance | 3 |
| Insurance contract or identification number | 40179 | | Number of Individuals Covered | 251 | | Insurance policy start date | 2022-03-01 | | Insurance policy end date | 2023-02-28 | | 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 $45,320 | | 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 | GLUG0BDLQ |
| Policy instance | 4 |
| Insurance contract or identification number | GLUG0BDLQ | | Number of Individuals Covered | 338 | | Insurance policy start date | 2022-03-01 | | Insurance policy end date | 2023-01-01 | | Total amount of commissions paid to insurance broker | USD $3,330 | | Total amount of fees paid to insurance company | USD $1,726 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,330 | | Amount paid for insurance broker fees | 1726 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
| Policy contract number | ETB013763 |
| Policy instance | 5 |
| Insurance contract or identification number | ETB013763 | | Insurance policy start date | 2022-03-01 | | Insurance policy end date | 2023-02-28 | | Total amount of commissions paid to insurance broker | USD $170 | | Total amount of fees paid to insurance company | USD $21 | | Other welfare benefits provided | BUSINESS TRAVEL ACCIDENT | | Welfare Benefit Premiums Paid to Carrier | USD $1,135 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $170 | | Amount paid for insurance broker fees | 21 | | 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 | GLUG0BDLQ |
| Policy instance | 1 |
| Insurance contract or identification number | GLUG0BDLQ | | Number of Individuals Covered | 302 | | Insurance policy start date | 2021-03-01 | | Insurance policy end date | 2022-03-01 | | Total amount of commissions paid to insurance broker | USD $3,803 | | Total amount of fees paid to insurance company | USD $1,639 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $21,730 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,803 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 1639 | | 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 | GLTD0BDLQ |
| Policy instance | 2 |
| Insurance contract or identification number | GLTD0BDLQ | | Number of Individuals Covered | 297 | | Insurance policy start date | 2021-03-01 | | Insurance policy end date | 2022-03-01 | | Total amount of commissions paid to insurance broker | USD $13,178 | | Total amount of fees paid to insurance company | USD $5,568 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $75,301 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $13,178 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 5568 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION |
|
| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
| Policy contract number | ETB013763 |
| Policy instance | 3 |
| Insurance contract or identification number | ETB013763 | | Insurance policy start date | 2021-03-01 | | Insurance policy end date | 2022-02-28 | | Total amount of commissions paid to insurance broker | USD $166 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | BUSINESS TRAVEL ACCIDENT | | Welfare Benefit Premiums Paid to Carrier | USD $1,104 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $166 | | Insurance broker organization code? | 3 |
|
| WYSSTA INSURANCE COMPANY INC. (National Association of Insurance Commissioners NAIC id number: 12352 ) |
| Policy contract number | 40179 |
| Policy instance | 4 |
| Insurance contract or identification number | 40179 | | Number of Individuals Covered | 233 | | Insurance policy start date | 2021-03-01 | | Insurance policy end date | 2022-02-28 | | 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 $42,077 | | 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 | GVTL0BDLQ |
| Policy instance | 5 |
| Insurance contract or identification number | GVTL0BDLQ | | Number of Individuals Covered | 214 | | Insurance policy start date | 2021-03-01 | | Insurance policy end date | 2022-03-01 | | Total amount of commissions paid to insurance broker | USD $15,349 | | Total amount of fees paid to insurance company | USD $6,315 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $87,708 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $15,349 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 6315 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION |
|
| WYSSTA INSURANCE COMPANY INC. (National Association of Insurance Commissioners NAIC id number: 12352 ) |
| Policy contract number | 40179 00000 |
| Policy instance | 5 |
| Insurance contract or identification number | 40179 00000 | | Number of Individuals Covered | 207 | | Insurance policy start date | 2020-03-01 | | Insurance policy end date | 2021-02-28 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $36,932 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
| Policy contract number | ETB013763 |
| Policy instance | 4 |
| Insurance contract or identification number | ETB013763 | | Number of Individuals Covered | 150 | | Insurance policy start date | 2020-03-01 | | Insurance policy end date | 2021-02-28 | | Total amount of commissions paid to insurance broker | USD $160 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | BUSINESS TRAVEL ACCIDENT | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $1,067 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $160 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GVTL0BDLQ |
| Policy instance | 3 |
| Insurance contract or identification number | GVTL0BDLQ | | Number of Individuals Covered | 209 | | Insurance policy start date | 2020-03-01 | | Insurance policy end date | 2021-02-28 | | Total amount of commissions paid to insurance broker | USD $14,116 | | Total amount of fees paid to insurance company | USD $7,140 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $80,663 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,067 | | Amount paid for insurance broker fees | 4284 | | 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 | GLUG0BDLQ |
| Policy instance | 2 |
| Insurance contract or identification number | GLUG0BDLQ | | Number of Individuals Covered | 290 | | Insurance policy start date | 2020-03-01 | | Insurance policy end date | 2021-02-28 | | Total amount of commissions paid to insurance broker | USD $3,630 | | Total amount of fees paid to insurance company | USD $1,917 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | AD&D | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $20,739 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,096 | | Amount paid for insurance broker fees | 1150 | | 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 | GLTD0BDLQ |
| Policy instance | 1 |
| Insurance contract or identification number | GLTD0BDLQ | | Number of Individuals Covered | 283 | | Insurance policy start date | 2020-03-01 | | Insurance policy end date | 2021-02-28 | | Total amount of commissions paid to insurance broker | USD $12,344 | | Total amount of fees paid to insurance company | USD $6,948 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | 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 $70,540 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,211 | | Amount paid for insurance broker fees | 4169 | | 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 | GLTD0BDLQ |
| Policy instance | 1 |
| Insurance contract or identification number | GLTD0BDLQ | | Number of Individuals Covered | 266 | | Insurance policy start date | 2019-03-01 | | Insurance policy end date | 2020-02-29 | | Total amount of commissions paid to insurance broker | USD $15,598 | | Total amount of fees paid to insurance company | USD $2,292 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | 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 $89,131 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $15,598 | | Amount paid for insurance broker fees | 1234 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
| Policy contract number | ETB013763 |
| Policy instance | 2 |
| Insurance contract or identification number | ETB013763 | | Insurance policy start date | 2019-03-01 | | Insurance policy end date | 2020-02-29 | | Total amount of commissions paid to insurance broker | USD $160 | | Total amount of fees paid to insurance company | USD $14 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | BUSINESS TRAVEL ACCIDENT | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $1,067 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $160 | | Amount paid for insurance broker fees | 14 | | Additional information about fees paid to insurance broker | BONUS PAID | | Insurance broker organization code? | 3 |
|
| WYSSTA INSURANCE COMPANY INC. (National Association of Insurance Commissioners NAIC id number: 12352 ) |
| Policy contract number | 4017900000 |
| Policy instance | 3 |
| Insurance contract or identification number | 4017900000 | | Number of Individuals Covered | 178 | | Insurance policy start date | 2019-03-01 | | Insurance policy end date | 2020-02-29 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | 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 $42,852 | | 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 | GLUG0BDLQ |
| Policy instance | 4 |
| Insurance contract or identification number | GLUG0BDLQ | | Number of Individuals Covered | 273 | | Insurance policy start date | 2019-03-01 | | Insurance policy end date | 2020-02-29 | | Total amount of commissions paid to insurance broker | USD $4,311 | | Total amount of fees paid to insurance company | USD $646 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | AD&D | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $24,637 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,311 | | Amount paid for insurance broker fees | 348 | | 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 | GVTL0BDLQ |
| Policy instance | 5 |
| Insurance contract or identification number | GVTL0BDLQ | | Number of Individuals Covered | 199 | | Insurance policy start date | 2019-03-01 | | Insurance policy end date | 2020-02-29 | | Total amount of commissions paid to insurance broker | USD $16,251 | | Total amount of fees paid to insurance company | USD $1,898 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $92,865 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $16,251 | | Amount paid for insurance broker fees | 1022 | | 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 | GLTD0BDLQ |
| Policy instance | 6 |
| Insurance contract or identification number | GLTD0BDLQ | | Number of Individuals Covered | 347 | | Insurance policy start date | 2018-08-01 | | Insurance policy end date | 2019-03-01 | | Total amount of commissions paid to insurance broker | USD $8,752 | | Total amount of fees paid to insurance company | USD $0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $50,014 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,752 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 ) |
| Policy contract number | 54807741 |
| Policy instance | 5 |
| Insurance contract or identification number | 54807741 | | Number of Individuals Covered | 327 | | Insurance policy start date | 2019-03-01 | | Insurance policy end date | 2018-07-31 | | Total amount of commissions paid to insurance broker | USD $4,885 | | Total amount of fees paid to insurance company | USD $0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $88,470 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,885 | | 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 | GUSIBBDLQ |
| Policy instance | 4 |
| Insurance contract or identification number | GUSIBBDLQ | | Number of Individuals Covered | 347 | | Insurance policy start date | 2018-08-01 | | Insurance policy end date | 2019-03-01 | | Total amount of commissions paid to insurance broker | USD $1,135 | | Total amount of fees paid to insurance company | USD $0 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | 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 $1,135 | | 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 | GLUG0BDLQ |
| Policy instance | 3 |
| Insurance contract or identification number | GLUG0BDLQ | | Number of Individuals Covered | 350 | | Insurance policy start date | 2018-08-01 | | Insurance policy end date | 2019-03-01 | | Total amount of commissions paid to insurance broker | USD $2,507 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $14,325 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,507 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| WYSSTA INSURANCE COMPANY INC. (National Association of Insurance Commissioners NAIC id number: 12352 ) |
| Policy contract number | 4017900000 |
| Policy instance | 2 |
| Insurance contract or identification number | 4017900000 | | Number of Individuals Covered | 218 | | Insurance policy start date | 2018-03-01 | | Insurance policy end date | 2019-02-28 | | 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 $38,912 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
| Policy contract number | ETB013763 |
| Policy instance | 1 |
| Insurance contract or identification number | ETB013763 | | Number of Individuals Covered | 344 | | Insurance policy start date | 2018-03-01 | | Insurance policy end date | 2019-02-28 | | Total amount of commissions paid to insurance broker | USD $320 | | Total amount of fees paid to insurance company | USD $32 | | Other welfare benefits provided | BUSINESS TRAVEL ACCIDENT | | Welfare Benefit Premiums Paid to Carrier | USD $1,067 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $160 | | Amount paid for insurance broker fees | 21 | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL OF WISCONSIN (National Association of Insurance Commissioners NAIC id number: 54046 ) |
| Policy contract number | 1231700000 |
| Policy instance | 1 |
| Insurance contract or identification number | 1231700000 | | Number of Individuals Covered | 125 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $3,864 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Insurance broker organization code? | 3 |
|
| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
| Policy contract number | ETB013763 |
| Policy instance | 1 |
| Insurance contract or identification number | ETB013763 | | Number of Individuals Covered | 287 | | Insurance policy start date | 2017-03-01 | | Insurance policy end date | 2018-02-28 | | Total amount of commissions paid to insurance broker | USD $160 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | BUSINESS TRAVEL ACCIDENT | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $1,067 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $160 | | Insurance broker organization code? | 3 | | Insurance broker name | WILLIS OF WISCONSIN |
|
| UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 ) |
| Policy contract number | 4025920 |
| Policy instance | 2 |
| Insurance contract or identification number | 4025920 | | Number of Individuals Covered | 311 | | Insurance policy start date | 2017-03-01 | | Insurance policy end date | 2018-02-28 | | Total amount of commissions paid to insurance broker | USD $3,418 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | 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 $269,072 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,630 | | Insurance broker organization code? | 3 | | Insurance broker name | JEFFREY M PRICKETTE |
|
| WYSSTA INSURANCE COMPANY INC. (National Association of Insurance Commissioners NAIC id number: 12352 ) |
| Policy contract number | 40179,40031 |
| Policy instance | 3 |
| Insurance contract or identification number | 40179,40031 | | Number of Individuals Covered | 180 | | Insurance policy start date | 2017-03-01 | | Insurance policy end date | 2018-02-28 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | 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 $29,952 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
| Policy contract number | ETB013763 |
| Policy instance | 1 |
| Insurance contract or identification number | ETB013763 | | Number of Individuals Covered | 271 | | Insurance policy start date | 2015-03-01 | | Insurance policy end date | 2016-02-28 | | Total amount of commissions paid to insurance broker | USD $160 | | Total amount of fees paid to insurance company | USD $16 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | BUSINESS TRAVEL ACCIDENT | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $1,067 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $160 | | Amount paid for insurance broker fees | 16 | | Additional information about fees paid to insurance broker | BONUS PAID | | Insurance broker organization code? | 3 | | Insurance broker name | WILLIS OF WISCONSIN |
|
| UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 ) |
| Policy contract number | G4025920 |
| Policy instance | 2 |
| Insurance contract or identification number | G4025920 | | Number of Individuals Covered | 220 | | Insurance policy start date | 2015-03-01 | | Insurance policy end date | 2016-02-28 | | 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 $148,102 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,481 | | Amount paid for insurance broker fees | 5208 | | Additional information about fees paid to insurance broker | NON-MONETARY COMPENSATION FEES PAID | | Insurance broker organization code? | 3 | | Insurance broker name | ASSOCIATED FINANCIAL GROUP |
|
| WYSSTA INSURANCE COMPANY INC. (National Association of Insurance Commissioners NAIC id number: 12352 ) |
| Policy contract number | 40179,40031 |
| Policy instance | 3 |
| Insurance contract or identification number | 40179,40031 | | Number of Individuals Covered | 125 | | Insurance policy start date | 2015-03-01 | | Insurance policy end date | 2016-02-28 | | 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 $21,052 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| WYSSTA INSURANCE COMPANY INC. (National Association of Insurance Commissioners NAIC id number: 12352 ) |
| Policy contract number | 40179,40031 |
| Policy instance | 2 |
| Insurance contract or identification number | 40179,40031 | | Number of Individuals Covered | 99 | | Insurance policy start date | 2014-03-01 | | Insurance policy end date | 2015-02-28 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | 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 $17,291 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
| Policy contract number | ETB013763 |
| Policy instance | 3 |
| Insurance contract or identification number | ETB013763 | | Number of Individuals Covered | 226 | | Insurance policy start date | 2014-03-01 | | Insurance policy end date | 2015-02-28 | | Total amount of commissions paid to insurance broker | USD $160 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | BUSINESS TRAVEL ACCIDENT | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $1,067 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $160 | | Insurance broker organization code? | 3 | | Insurance broker name | WILLIS OF WISCONSIN |
|
| UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 ) |
| Policy contract number | G4025920 |
| Policy instance | 1 |
| Insurance contract or identification number | G4025920 | | Number of Individuals Covered | 210 | | Insurance policy start date | 2014-03-01 | | Insurance policy end date | 2015-02-28 | | Total amount of commissions paid to insurance broker | USD $5,366 | | Total amount of fees paid to insurance company | USD $4,218 | | 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 $136,591 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,366 | | Amount paid for insurance broker fees | 4218 | | Additional information about fees paid to insurance broker | NON-MONETARY COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | ASSOCIATED FINANCIAL GROUP |
|
| UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 ) |
| Policy contract number | G4025920 |
| Policy instance | 1 |
| Insurance contract or identification number | G4025920 | | Number of Individuals Covered | 197 | | Insurance policy start date | 2013-03-01 | | Insurance policy end date | 2014-02-28 | | Total amount of commissions paid to insurance broker | USD $5,270 | | Total amount of fees paid to insurance company | USD $15 | | 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 $126,973 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,270 | | Amount paid for insurance broker fees | 15 | | Additional information about fees paid to insurance broker | NON-MONETARY COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | ASSOCIATED FINANCIAL GROUP |
|
| WYSSTA INSURANCE COMPANY INC. (National Association of Insurance Commissioners NAIC id number: 12352 ) |
| Policy contract number | 40179,40031 |
| Policy instance | 2 |
| Insurance contract or identification number | 40179,40031 | | Number of Individuals Covered | 81 | | Insurance policy start date | 2013-03-01 | | Insurance policy end date | 2014-02-28 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | 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 $3,254 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
| Policy contract number | ETB013763 |
| Policy instance | 3 |
| Insurance contract or identification number | ETB013763 | | 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 $160 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | BUSINESS TRAVEL ACCIDENT | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $1,067 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $160 | | Insurance broker organization code? | 3 | | Insurance broker name | WILLIS OF WISCONSIN |
|
| UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 ) |
| Policy contract number | G4025920 |
| Policy instance | 1 |
| Insurance contract or identification number | G4025920 | | Number of Individuals Covered | 177 | | Insurance policy start date | 2012-03-01 | | Insurance policy end date | 2013-02-28 | | Total amount of commissions paid to insurance broker | USD $7,988 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | 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 $164,846 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,988 | | Insurance broker organization code? | 3 | | Insurance broker name | ASSOCIATED FINANCIAL GROUP |
|
| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
| Policy contract number | ETB013763 |
| Policy instance | 3 |
| Insurance contract or identification number | ETB013763 | | Number of Individuals Covered | 204 | | Insurance policy start date | 2012-03-01 | | Insurance policy end date | 2013-02-28 | | Total amount of commissions paid to insurance broker | USD $160 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | BUSINESS TRAVEL ACCIDENT | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $1,067 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $160 | | Insurance broker organization code? | 3 | | Insurance broker name | WILLIS OF WISCONSIN |
|
| WYSSTA INSURANCE COMPANY INC. (National Association of Insurance Commissioners NAIC id number: 12352 ) |
| Policy contract number | 40179,40031 |
| Policy instance | 2 |
| Insurance contract or identification number | 40179,40031 | | Number of Individuals Covered | 71 | | Insurance policy start date | 2012-03-01 | | Insurance policy end date | 2013-02-28 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | 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 $12,998 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| WYSSTA INSURANCE COMPANY INC. (National Association of Insurance Commissioners NAIC id number: 12352 ) |
| Policy contract number | 40179,40031 |
| Policy instance | 3 |
| Insurance contract or identification number | 40179,40031 | | Number of Individuals Covered | 57 | | Insurance policy start date | 2011-03-01 | | Insurance policy end date | 2012-02-29 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | 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 $10,896 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 ) |
| Policy contract number | G4025920 |
| Policy instance | 2 |
| Insurance contract or identification number | G4025920 | | Number of Individuals Covered | 155 | | Insurance policy start date | 2011-03-01 | | Insurance policy end date | 2012-02-29 | | Total amount of commissions paid to insurance broker | USD $8,028 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | 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 $160,497 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
| Policy contract number | ETB013763 |
| Policy instance | 1 |
| Insurance contract or identification number | ETB013763 | | Number of Individuals Covered | 161 | | Insurance policy start date | 2011-03-01 | | Insurance policy end date | 2012-02-29 | | Total amount of commissions paid to insurance broker | USD $160 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | BUSINESS TRAVEL ACCIDENT | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $1,067 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| WYSSTA INSURANCE COMPANY INC. (National Association of Insurance Commissioners NAIC id number: 12352 ) |
| Policy contract number | 40179,40031 |
| Policy instance | 2 |
| Insurance contract or identification number | 40179,40031 | | Number of Individuals Covered | 51 | | Insurance policy start date | 2010-03-01 | | Insurance policy end date | 2011-02-28 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | 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 $7,563 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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| UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 ) |
| Policy contract number | G4025920 |
| Policy instance | 1 |
| Insurance contract or identification number | G4025920 | | Number of Individuals Covered | 147 | | Insurance policy start date | 2010-03-01 | | Insurance policy end date | 2011-02-28 | | Total amount of commissions paid to insurance broker | USD $7,926 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | 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 $154,764 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,926 | | Insurance broker organization code? | 3 | | Insurance broker name | ASSOCIATED FINANCIAL GROUP |
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