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ANDROSCOGGIN BANK GROUP BENEFIT PLAN 401k Plan overview

Plan NameANDROSCOGGIN BANK GROUP BENEFIT PLAN
Plan identification number 502

ANDROSCOGGIN BANK GROUP BENEFIT PLAN Benefits

401k Plan TypeWelfare Benefit
Plan Features/Benefits
  • Health (other than dental or vision)
  • Life insurance
  • Dental
  • Vision
  • Temporary disability (accident and sickness)
  • Long-term disability cover
  • Other welfare benefit cover
  • Unfunded, fully insured, or combination unfunded/insured welfare plan that will not file a Form 5500 for next plan year pursuant to 29 CFR 2520.104-20.

401k Sponsoring company profile

ANDROSCOGGIN SAVINGS BANK has sponsored the creation of one or more 401k plans.

Company Name:ANDROSCOGGIN SAVINGS BANK
Employer identification number (EIN):010020240
NAIC Classification:522110
NAIC Description:Commercial Banking

Form 5500 Filing Information

Submission information for form 5500 for 401k plan ANDROSCOGGIN BANK GROUP BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5022022-01-01MICHELLE ALLEN2023-07-18
5022021-01-01MICHELLE Y. LOVE2022-07-14
5022020-01-01MICHELLE Y. LOVE2021-07-28
5022019-01-01MICHELLE Y. LOVE2020-07-29
5022018-01-01MICHELLE Y. LOVE2019-07-31
5022017-07-01
5022016-07-01
5022015-07-01
5022014-07-01
5022013-07-01MICHAEL LETOURNEAU MICHAEL LETOURNEAU2015-01-30
5022012-07-01MICHAEL LETOURNEAU MICHAEL LETOURNEAU2015-01-22
5022011-07-01DAVID PEASE DAVID PEASE2012-11-29
5022009-07-01DAVID PEASE DAVID PEASE2011-01-24

Plan Statistics for ANDROSCOGGIN BANK GROUP BENEFIT PLAN

401k plan membership statisitcs for ANDROSCOGGIN BANK GROUP BENEFIT PLAN

Measure Date Value
2022: ANDROSCOGGIN BANK GROUP BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year2022-01-01198
Total number of active participants reported on line 7a of the Form 55002022-01-01211
Number of retired or separated participants receiving benefits2022-01-013
Total of all active and inactive participants2022-01-01214
2021: ANDROSCOGGIN BANK GROUP BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year2021-01-01172
Total number of active participants reported on line 7a of the Form 55002021-01-01168
Number of retired or separated participants receiving benefits2021-01-015
Total of all active and inactive participants2021-01-01173
2020: ANDROSCOGGIN BANK GROUP BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year2020-01-01201
Total number of active participants reported on line 7a of the Form 55002020-01-01198
Total of all active and inactive participants2020-01-01198
2019: ANDROSCOGGIN BANK GROUP BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year2019-01-01182
Total number of active participants reported on line 7a of the Form 55002019-01-01206
Number of retired or separated participants receiving benefits2019-01-013
Number of other retired or separated participants entitled to future benefits2019-01-011
Total of all active and inactive participants2019-01-01210
2018: ANDROSCOGGIN BANK GROUP BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year2018-01-01194
Total number of active participants reported on line 7a of the Form 55002018-01-01174
Number of retired or separated participants receiving benefits2018-01-017
Number of other retired or separated participants entitled to future benefits2018-01-011
Total of all active and inactive participants2018-01-01182
2017: ANDROSCOGGIN BANK GROUP BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year2017-07-01184
Total number of active participants reported on line 7a of the Form 55002017-07-01185
Number of retired or separated participants receiving benefits2017-07-019
Number of other retired or separated participants entitled to future benefits2017-07-010
Total of all active and inactive participants2017-07-01194
2016: ANDROSCOGGIN BANK GROUP BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year2016-07-01302
Total number of active participants reported on line 7a of the Form 55002016-07-01314
Number of retired or separated participants receiving benefits2016-07-0120
Number of other retired or separated participants entitled to future benefits2016-07-0120
Total of all active and inactive participants2016-07-01354
2015: ANDROSCOGGIN BANK GROUP BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year2015-07-01289
Total number of active participants reported on line 7a of the Form 55002015-07-01302
Number of retired or separated participants receiving benefits2015-07-015
Number of other retired or separated participants entitled to future benefits2015-07-014
Total of all active and inactive participants2015-07-01311
2014: ANDROSCOGGIN BANK GROUP BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year2014-07-01280
Total number of active participants reported on line 7a of the Form 55002014-07-01282
Number of retired or separated participants receiving benefits2014-07-017
Total of all active and inactive participants2014-07-01289
2013: ANDROSCOGGIN BANK GROUP BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year2013-07-01158
Total number of active participants reported on line 7a of the Form 55002013-07-01158
Total of all active and inactive participants2013-07-01158
2012: ANDROSCOGGIN BANK GROUP BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year2012-07-01157
Total number of active participants reported on line 7a of the Form 55002012-07-01158
Number of retired or separated participants receiving benefits2012-07-010
Number of other retired or separated participants entitled to future benefits2012-07-010
Total of all active and inactive participants2012-07-01158
2011: ANDROSCOGGIN BANK GROUP BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year2011-07-01171
Total number of active participants reported on line 7a of the Form 55002011-07-01149
Number of retired or separated participants receiving benefits2011-07-018
Total of all active and inactive participants2011-07-01157
2009: ANDROSCOGGIN BANK GROUP BENEFIT PLAN 2009 401k membership
Total participants, beginning-of-year2009-07-01178
Total number of active participants reported on line 7a of the Form 55002009-07-01187
Number of retired or separated participants receiving benefits2009-07-0111
Number of other retired or separated participants entitled to future benefits2009-07-010
Total of all active and inactive participants2009-07-01198

Form 5500 Responses for ANDROSCOGGIN BANK GROUP BENEFIT PLAN

2022: ANDROSCOGGIN BANK GROUP BENEFIT PLAN 2022 form 5500 responses
2022-01-01Type of plan entitySingle employer plan
2022-01-01Plan funding arrangement – InsuranceYes
2022-01-01Plan funding arrangement – General assets of the sponsorYes
2022-01-01Plan benefit arrangement – InsuranceYes
2022-01-01Plan benefit arrangement – General assets of the sponsorYes
2021: ANDROSCOGGIN BANK GROUP BENEFIT PLAN 2021 form 5500 responses
2021-01-01Type of plan entitySingle employer plan
2021-01-01Plan funding arrangement – InsuranceYes
2021-01-01Plan funding arrangement – General assets of the sponsorYes
2021-01-01Plan benefit arrangement – InsuranceYes
2021-01-01Plan benefit arrangement – General assets of the sponsorYes
2020: ANDROSCOGGIN BANK GROUP BENEFIT PLAN 2020 form 5500 responses
2020-01-01Type of plan entitySingle employer plan
2020-01-01Plan funding arrangement – InsuranceYes
2020-01-01Plan funding arrangement – General assets of the sponsorYes
2020-01-01Plan benefit arrangement – InsuranceYes
2020-01-01Plan benefit arrangement – General assets of the sponsorYes
2019: ANDROSCOGGIN BANK GROUP BENEFIT PLAN 2019 form 5500 responses
2019-01-01Type of plan entitySingle employer plan
2019-01-01Plan funding arrangement – InsuranceYes
2019-01-01Plan funding arrangement – General assets of the sponsorYes
2019-01-01Plan benefit arrangement – InsuranceYes
2019-01-01Plan benefit arrangement – General assets of the sponsorYes
2018: ANDROSCOGGIN BANK GROUP BENEFIT PLAN 2018 form 5500 responses
2018-01-01Type of plan entitySingle employer plan
2018-01-01Plan funding arrangement – InsuranceYes
2018-01-01Plan funding arrangement – General assets of the sponsorYes
2018-01-01Plan benefit arrangement – InsuranceYes
2018-01-01Plan benefit arrangement – General assets of the sponsorYes
2017: ANDROSCOGGIN BANK GROUP BENEFIT PLAN 2017 form 5500 responses
2017-07-01Type of plan entitySingle employer plan
2017-07-01This return/report is a short plan year return/report (less than 12 months)Yes
2017-07-01Plan funding arrangement – InsuranceYes
2017-07-01Plan benefit arrangement – InsuranceYes
2016: ANDROSCOGGIN BANK GROUP BENEFIT PLAN 2016 form 5500 responses
2016-07-01Type of plan entitySingle employer plan
2016-07-01Plan funding arrangement – InsuranceYes
2016-07-01Plan benefit arrangement – InsuranceYes
2015: ANDROSCOGGIN BANK GROUP BENEFIT PLAN 2015 form 5500 responses
2015-07-01Type of plan entitySingle employer plan
2015-07-01Plan funding arrangement – InsuranceYes
2015-07-01Plan benefit arrangement – InsuranceYes
2014: ANDROSCOGGIN BANK GROUP BENEFIT PLAN 2014 form 5500 responses
2014-07-01Type of plan entitySingle employer plan
2014-07-01Plan funding arrangement – InsuranceYes
2014-07-01Plan benefit arrangement – InsuranceYes
2013: ANDROSCOGGIN BANK GROUP BENEFIT PLAN 2013 form 5500 responses
2013-07-01Type of plan entitySingle employer plan
2013-07-01Submission has been amendedNo
2013-07-01This submission is the final filingNo
2013-07-01This return/report is a short plan year return/report (less than 12 months)No
2013-07-01Plan is a collectively bargained planNo
2013-07-01Plan funding arrangement – InsuranceYes
2013-07-01Plan funding arrangement – General assets of the sponsorYes
2013-07-01Plan benefit arrangement – InsuranceYes
2012: ANDROSCOGGIN BANK GROUP BENEFIT PLAN 2012 form 5500 responses
2012-07-01Type of plan entitySingle employer plan
2012-07-01Submission has been amendedYes
2012-07-01This submission is the final filingNo
2012-07-01This return/report is a short plan year return/report (less than 12 months)No
2012-07-01Plan is a collectively bargained planNo
2012-07-01Plan funding arrangement – InsuranceYes
2012-07-01Plan funding arrangement – General assets of the sponsorYes
2012-07-01Plan benefit arrangement – InsuranceYes
2011: ANDROSCOGGIN BANK GROUP BENEFIT PLAN 2011 form 5500 responses
2011-07-01Type of plan entitySingle employer plan
2011-07-01Submission has been amendedNo
2011-07-01This submission is the final filingNo
2011-07-01This return/report is a short plan year return/report (less than 12 months)No
2011-07-01Plan is a collectively bargained planNo
2011-07-01Plan funding arrangement – InsuranceYes
2011-07-01Plan benefit arrangement – InsuranceYes
2009: ANDROSCOGGIN BANK GROUP BENEFIT PLAN 2009 form 5500 responses
2009-07-01Type of plan entitySingle employer plan
2009-07-01Submission has been amendedNo
2009-07-01This submission is the final filingNo
2009-07-01This return/report is a short plan year return/report (less than 12 months)No
2009-07-01Plan is a collectively bargained planNo
2009-07-01Plan funding arrangement – InsuranceYes
2009-07-01Plan benefit arrangement – InsuranceYes

Insurance Providers Used on plan

HPHC INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 18975 )
Policy contract number112132
Policy instance 8
Insurance contract or identification number112132
Number of Individuals Covered24
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $3,051
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $99,717
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,051
Insurance broker organization code?3
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number30093553
Policy instance 1
Insurance contract or identification number30093553
Number of Individuals Covered162
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $1,467
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $20,380
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,467
Insurance broker organization code?3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number956067
Policy instance 2
Insurance contract or identification number956067
Number of Individuals Covered211
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $10,667
Total amount of fees paid to insurance companyUSD $4,268
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $138,387
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $10,667
Insurance broker organization code?3
Amount paid for insurance broker fees4268
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION PAID
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number956068
Policy instance 3
Insurance contract or identification number956068
Number of Individuals Covered128
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $8,910
Total amount of fees paid to insurance companyUSD $1,786
Life Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $59,397
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $8,910
Insurance broker organization code?3
Amount paid for insurance broker fees1786
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION PAID
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract numberR0791491
Policy instance 4
Insurance contract or identification numberR0791491
Number of Individuals Covered71
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $2,020
Total amount of fees paid to insurance companyUSD $2
Other welfare benefits providedCRITICAL ILLNESS & ACCIDENT
Welfare Benefit Premiums Paid to CarrierUSD $25,949
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,211
Amount paid for insurance broker fees1
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION PAID
Insurance broker organization code?3
HPHC INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 18975 )
Policy contract number112129
Policy instance 5
Insurance contract or identification number112129
Number of Individuals Covered254
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $36,074
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,179,501
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $36,074
Insurance broker organization code?3
HPHC INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 18975 )
Policy contract number112130
Policy instance 6
Insurance contract or identification number112130
Number of Individuals Covered51
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $5,237
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $183,168
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,237
Insurance broker organization code?3
HPHC INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 18975 )
Policy contract number112131
Policy instance 7
Insurance contract or identification number112131
Number of Individuals Covered90
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $14,714
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $491,259
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $14,714
Insurance broker organization code?3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract numberR0791491
Policy instance 5
Insurance contract or identification numberR0791491
Number of Individuals Covered79
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $3,335
Total amount of fees paid to insurance companyUSD $82
Other welfare benefits providedCRITICAL ILLNESS & ACCIDENT
Welfare Benefit Premiums Paid to CarrierUSD $24,082
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,001
Amount paid for insurance broker fees47
Insurance broker organization code?3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number956068
Policy instance 4
Insurance contract or identification number956068
Number of Individuals Covered121
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $7,585
Total amount of fees paid to insurance companyUSD $2,462
Life Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $49,232
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $7,585
Insurance broker organization code?3
Amount paid for insurance broker fees2462
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION PAID
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number956067
Policy instance 3
Insurance contract or identification number956067
Number of Individuals Covered193
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $10,917
Total amount of fees paid to insurance companyUSD $6,417
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $128,334
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $10,917
Insurance broker organization code?3
Amount paid for insurance broker fees6417
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION PAID
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number30093553
Policy instance 2
Insurance contract or identification number30093553
Number of Individuals Covered151
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $1,079
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $19,223
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,079
Insurance broker organization code?3
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number0619960
Policy instance 1
Insurance contract or identification number0619960
Number of Individuals Covered384
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $47,091
Total amount of fees paid to insurance companyUSD $5,700
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,581,895
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $47,091
Amount paid for insurance broker fees5700
Additional information about fees paid to insurance brokerMEDICAL RETENTION INCENTIVE RISK
Insurance broker organization code?3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract numberR0791491
Policy instance 4
Insurance contract or identification numberR0791491
Number of Individuals Covered96
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $17,955
Total amount of fees paid to insurance companyUSD $860
Other welfare benefits providedACCIDENT & CRITICAL ILLNESS
Welfare Benefit Premiums Paid to CarrierUSD $27,597
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $10,773
Amount paid for insurance broker fees496
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
Insurance broker organization code?3
ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 )
Policy contract numberAL00005878
Policy instance 3
Insurance contract or identification numberAL00005878
Number of Individuals Covered194
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $21,504
Total amount of fees paid to insurance companyUSD $1,486
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedAD&D AND EAP
Welfare Benefit Premiums Paid to CarrierUSD $158,371
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $21,504
Amount paid for insurance broker fees1486
Insurance broker organization code?3
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number30093553
Policy instance 2
Insurance contract or identification number30093553
Number of Individuals Covered142
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $1,033
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $17,936
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,033
Insurance broker organization code?3
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number0619960
Policy instance 1
Insurance contract or identification number0619960
Number of Individuals Covered387
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $45,448
Total amount of fees paid to insurance companyUSD $3,820
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,523,642
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $45,448
Amount paid for insurance broker fees3820
Additional information about fees paid to insurance brokerMEDICAL RETENTION RISK
Insurance broker organization code?3
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number0619960
Policy instance 1
Insurance contract or identification number0619960
Number of Individuals Covered377
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $40,147
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,333,871
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $26,478
Insurance broker organization code?3
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number30026008
Policy instance 2
Insurance contract or identification number30026008
Number of Individuals Covered0
Insurance policy start date2019-01-01
Insurance policy end date2019-06-30
Total amount of commissions paid to insurance brokerUSD $646
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $7,916
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $646
Insurance broker organization code?3
ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 )
Policy contract numberAL00005878
Policy instance 3
Insurance contract or identification numberAL00005878
Number of Individuals Covered196
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $23,814
Total amount of fees paid to insurance companyUSD $4,950
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $146,876
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $23,814
Amount paid for insurance broker fees4950
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
ANTHEM HEALTH PLANS OF MAINE, INC. (National Association of Insurance Commissioners NAIC id number: 52618 )
Policy contract number00C129
Policy instance 4
Insurance contract or identification number00C129
Number of Individuals Covered135
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $1,421
Total amount of fees paid to insurance companyUSD $3,750
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $15,548
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,421
Amount paid for insurance broker fees3750
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 )
Policy contract numberAL00005878
Policy instance 3
Insurance contract or identification numberAL00005878
Number of Individuals Covered188
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $17,246
Total amount of fees paid to insurance companyUSD $7,437
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $141,077
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $15,595
Amount paid for insurance broker fees7437
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number30026008
Policy instance 2
Insurance contract or identification number30026008
Number of Individuals Covered122
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $16,005
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number0619960
Policy instance 1
Insurance contract or identification number0619960
Number of Individuals Covered343
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $42,356
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,328,067
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $42,356
Insurance broker organization code?3
ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 )
Policy contract numberAL00005878
Policy instance 3
Insurance contract or identification numberAL00005878
Number of Individuals Covered185
Insurance policy start date2017-07-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $9,361
Total amount of fees paid to insurance companyUSD $0
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $64,150
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $9,361
Insurance broker organization code?3
Insurance broker nameHOLDEN AGENCY
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number30026008
Policy instance 2
Insurance contract or identification number30026008
Number of Individuals Covered112
Insurance policy start date2017-07-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $623
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $7,466
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $623
Insurance broker organization code?3
Insurance broker nameHOLDEN AGENCY
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number0619960
Policy instance 1
Insurance contract or identification number0619960
Number of Individuals Covered329
Insurance policy start date2017-07-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $16,633
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $654,149
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $16,633
Insurance broker organization code?3
Insurance broker nameHOLDEN AGENCY

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