PRESIDENT & FELLOWS OF MIDDLEBURY COLLEGE has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan MIDDLEBURY COLLEGE HEALTH AND WELFARE BENEFITS PLAN
401k plan membership statisitcs for MIDDLEBURY COLLEGE HEALTH AND WELFARE BENEFITS PLAN
| Measure | Date | Value |
|---|
| 2023 : MIDDLEBURY COLLEGE HEALTH AND WELFARE BENEFITS PLAN 2023 401k financial data |
|---|
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2023-12-31 | No |
| Was this plan covered by a fidelity bond | 2023-12-31 | No |
| If this is an individual account plan, was there a blackout period | 2023-12-31 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2023-12-31 | No |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2023-12-31 | No |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2023-12-31 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2023-12-31 | No |
| Were any leases to which the plan was party in default or uncollectible | 2023-12-31 | No |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2023-12-31 | No |
| Was there a failure to transmit to the plan any participant contributions | 2023-12-31 | No |
| Has the plan failed to provide any benefit when due under the plan | 2023-12-31 | No |
| Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-3 | 2023-12-31 | No |
| Did the plan have assets held for investment | 2023-12-31 | No |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2023-12-31 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2023-12-31 | No |
| 2022 : MIDDLEBURY COLLEGE HEALTH AND WELFARE BENEFITS PLAN 2022 401k financial data |
|---|
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2022-12-31 | No |
| Was this plan covered by a fidelity bond | 2022-12-31 | No |
| If this is an individual account plan, was there a blackout period | 2022-12-31 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2022-12-31 | No |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2022-12-31 | No |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2022-12-31 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2022-12-31 | No |
| Were any leases to which the plan was party in default or uncollectible | 2022-12-31 | No |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2022-12-31 | No |
| Was there a failure to transmit to the plan any participant contributions | 2022-12-31 | No |
| Has the plan failed to provide any benefit when due under the plan | 2022-12-31 | No |
| Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-3 | 2022-12-31 | No |
| Did the plan have assets held for investment | 2022-12-31 | No |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2022-12-31 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2022-12-31 | No |
| 2021 : MIDDLEBURY COLLEGE HEALTH AND WELFARE BENEFITS PLAN 2021 401k financial data |
|---|
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2021-12-31 | No |
| Was this plan covered by a fidelity bond | 2021-12-31 | No |
| If this is an individual account plan, was there a blackout period | 2021-12-31 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2021-12-31 | No |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2021-12-31 | No |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2021-12-31 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2021-12-31 | No |
| Were any leases to which the plan was party in default or uncollectible | 2021-12-31 | No |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2021-12-31 | No |
| Was there a failure to transmit to the plan any participant contributions | 2021-12-31 | No |
| Has the plan failed to provide any benefit when due under the plan | 2021-12-31 | No |
| Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-3 | 2021-12-31 | No |
| Did the plan have assets held for investment | 2021-12-31 | No |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2021-12-31 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2021-12-31 | No |
| 2020 : MIDDLEBURY COLLEGE HEALTH AND WELFARE BENEFITS PLAN 2020 401k financial data |
|---|
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2020-12-31 | No |
| Was this plan covered by a fidelity bond | 2020-12-31 | No |
| If this is an individual account plan, was there a blackout period | 2020-12-31 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2020-12-31 | No |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2020-12-31 | No |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2020-12-31 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2020-12-31 | No |
| Were any leases to which the plan was party in default or uncollectible | 2020-12-31 | No |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2020-12-31 | No |
| Was there a failure to transmit to the plan any participant contributions | 2020-12-31 | No |
| Has the plan failed to provide any benefit when due under the plan | 2020-12-31 | No |
| Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-3 | 2020-12-31 | No |
| Did the plan have assets held for investment | 2020-12-31 | No |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2020-12-31 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2020-12-31 | No |
| 2019 : MIDDLEBURY COLLEGE HEALTH AND WELFARE BENEFITS PLAN 2019 401k financial data |
|---|
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2019-12-31 | No |
| Was this plan covered by a fidelity bond | 2019-12-31 | No |
| If this is an individual account plan, was there a blackout period | 2019-12-31 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2019-12-31 | No |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2019-12-31 | No |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2019-12-31 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2019-12-31 | No |
| Were any leases to which the plan was party in default or uncollectible | 2019-12-31 | No |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2019-12-31 | No |
| Was there a failure to transmit to the plan any participant contributions | 2019-12-31 | No |
| Has the plan failed to provide any benefit when due under the plan | 2019-12-31 | No |
| Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-3 | 2019-12-31 | No |
| Did the plan have assets held for investment | 2019-12-31 | No |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2019-12-31 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2019-12-31 | No |
| 2018 : MIDDLEBURY COLLEGE HEALTH AND WELFARE BENEFITS PLAN 2018 401k financial data |
|---|
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2018-12-31 | No |
| Was this plan covered by a fidelity bond | 2018-12-31 | No |
| If this is an individual account plan, was there a blackout period | 2018-12-31 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2018-12-31 | No |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2018-12-31 | No |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2018-12-31 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2018-12-31 | No |
| Were any leases to which the plan was party in default or uncollectible | 2018-12-31 | No |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2018-12-31 | No |
| Was there a failure to transmit to the plan any participant contributions | 2018-12-31 | No |
| Has the plan failed to provide any benefit when due under the plan | 2018-12-31 | No |
| Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-3 | 2018-12-31 | No |
| Did the plan have assets held for investment | 2018-12-31 | No |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2018-12-31 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2018-12-31 | No |
| 2017 : MIDDLEBURY COLLEGE HEALTH AND WELFARE BENEFITS PLAN 2017 401k financial data |
|---|
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2017-12-31 | No |
| Was this plan covered by a fidelity bond | 2017-12-31 | No |
| If this is an individual account plan, was there a blackout period | 2017-12-31 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2017-12-31 | No |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2017-12-31 | No |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2017-12-31 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2017-12-31 | No |
| Were any leases to which the plan was party in default or uncollectible | 2017-12-31 | No |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2017-12-31 | No |
| Was there a failure to transmit to the plan any participant contributions | 2017-12-31 | No |
| Has the plan failed to provide any benefit when due under the plan | 2017-12-31 | No |
| Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-3 | 2017-12-31 | No |
| Did the plan have assets held for investment | 2017-12-31 | No |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2017-12-31 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2017-12-31 | No |
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 469869 |
| Policy instance | 3 |
| Insurance contract or identification number | 469869 | | Number of Individuals Covered | 1415 | | Insurance policy start date | 2023-01-01 | | Insurance policy end date | 2023-12-31 | | Total amount of commissions paid to insurance broker | USD $13,647 | | Total amount of fees paid to insurance company | USD $9,721 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ADD | | Welfare Benefit Premiums Paid to Carrier | USD $777,714 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 30022396 |
| Policy instance | 1 |
| Insurance contract or identification number | 30022396 | | Number of Individuals Covered | 1186 | | Insurance policy start date | 2023-01-01 | | Insurance policy end date | 2023-12-31 | | Total amount of commissions paid to insurance broker | USD $5,082 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $304,432 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 469871 |
| Policy instance | 2 |
| Insurance contract or identification number | 469871 | | Number of Individuals Covered | 496 | | Insurance policy start date | 2023-01-01 | | Insurance policy end date | 2023-12-31 | | Total amount of commissions paid to insurance broker | USD $50,844 | | Total amount of fees paid to insurance company | USD $4,237 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ADD | | Welfare Benefit Premiums Paid to Carrier | USD $338,961 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| PAUL REVERE VARIABLE ANNUITY INS. CO. (National Association of Insurance Commissioners NAIC id number: 67601 ) |
| Policy contract number | 682819 |
| Policy instance | 10 |
| Insurance contract or identification number | 682819 | | Number of Individuals Covered | 234 | | Insurance policy start date | 2023-01-01 | | Insurance policy end date | 2023-12-31 | | Total amount of commissions paid to insurance broker | USD $11,993 | | Total amount of fees paid to insurance company | USD $999 | | Other welfare benefits provided | CRITICAL ILLNESS | | Welfare Benefit Premiums Paid to Carrier | USD $79,956 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
| Policy contract number | 3339660 |
| Policy instance | 4 |
| Insurance contract or identification number | 3339660 | | Number of Individuals Covered | 2696 | | Insurance policy start date | 2023-01-01 | | Insurance policy end date | 2023-12-31 | | Total amount of commissions paid to insurance broker | USD $172,191 | | Total amount of fees paid to insurance company | USD $64,576 | | Welfare Benefit Premiums Paid to Carrier | USD $2,152,538 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
| Policy contract number | 02301A |
| Policy instance | 5 |
| Insurance contract or identification number | 02301A | | Number of Individuals Covered | 1 | | Insurance policy start date | 2023-01-01 | | Insurance policy end date | 2023-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | MBA | | Welfare Benefit Premiums Paid to Carrier | USD $20,400 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | R0797290 |
| Policy instance | 6 |
| Insurance contract or identification number | R0797290 | | Number of Individuals Covered | 3 | | Insurance policy start date | 2023-01-01 | | Insurance policy end date | 2023-12-31 | | Total amount of commissions paid to insurance broker | USD $93 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | GCIEE GRPACCVOEN | | Welfare Benefit Premiums Paid to Carrier | USD $1,075 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 ) |
| Policy contract number | 699685 |
| Policy instance | 7 |
| Insurance contract or identification number | 699685 | | Number of Individuals Covered | 6 | | Insurance policy start date | 2023-01-01 | | Insurance policy end date | 2023-12-31 | | Total amount of commissions paid to insurance broker | USD $226 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | DBL | | Welfare Benefit Premiums Paid to Carrier | USD $1,855 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 ) |
| Policy contract number | 0012708549 |
| Policy instance | 8 |
| Insurance contract or identification number | 0012708549 | | Number of Individuals Covered | 84 | | Insurance policy start date | 2023-01-01 | | Insurance policy end date | 2023-12-31 | | Total amount of commissions paid to insurance broker | USD $1,256 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | WHOLE LIFE | | Welfare Benefit Premiums Paid to Carrier | USD $25,131 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| PAUL REVERE VARIABLE ANNUITY INS. CO. (National Association of Insurance Commissioners NAIC id number: 67601 ) |
| Policy contract number | 682820 |
| Policy instance | 9 |
| Insurance contract or identification number | 682820 | | Number of Individuals Covered | 195 | | Insurance policy start date | 2023-01-01 | | Insurance policy end date | 2023-12-31 | | Total amount of commissions paid to insurance broker | USD $4,556 | | Total amount of fees paid to insurance company | USD $718 | | Other welfare benefits provided | GRP ACCIDENT | | Welfare Benefit Premiums Paid to Carrier | USD $43,446 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 30022396 |
| Policy instance | 1 |
| Insurance contract or identification number | 30022396 | | Number of Individuals Covered | 957 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $5,334 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $293,148 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,334 | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 469871 |
| Policy instance | 2 |
| Insurance contract or identification number | 469871 | | Number of Individuals Covered | 531 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $56,226 | | Total amount of fees paid to insurance company | USD $4,686 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ADD | | Welfare Benefit Premiums Paid to Carrier | USD $374,841 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $56,226 | | Amount paid for insurance broker fees | 4686 | | Additional information about fees paid to insurance broker | GENERAL FEES | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 469869 |
| Policy instance | 3 |
| Insurance contract or identification number | 469869 | | Number of Individuals Covered | 1399 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $14,215 | | Total amount of fees paid to insurance company | USD $10,475 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ADD | | Welfare Benefit Premiums Paid to Carrier | USD $838,026 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $14,215 | | Amount paid for insurance broker fees | 10475 | | Additional information about fees paid to insurance broker | GENERAL FEES | | Insurance broker organization code? | 3 |
|
| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
| Policy contract number | 3339660 |
| Policy instance | 4 |
| Insurance contract or identification number | 3339660 | | Number of Individuals Covered | 2683 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $151,700 | | Total amount of fees paid to insurance company | USD $56,899 | | Welfare Benefit Premiums Paid to Carrier | USD $1,896,364 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $151,700 | | Amount paid for insurance broker fees | 56899 | | Additional information about fees paid to insurance broker | SERVICE/GENERAL AGENT FEES | | Insurance broker organization code? | 3 |
|
| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
| Policy contract number | 02301A |
| Policy instance | 5 |
| Insurance contract or identification number | 02301A | | Number of Individuals Covered | 1 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | MBA | | Welfare Benefit Premiums Paid to Carrier | USD $20,400 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 ) |
| Policy contract number | 699685 |
| Policy instance | 7 |
| Insurance contract or identification number | 699685 | | Number of Individuals Covered | 6 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $378 | | Total amount of fees paid to insurance company | USD $32 | | Other welfare benefits provided | DBL | | Welfare Benefit Premiums Paid to Carrier | USD $2,519 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $378 | | Amount paid for insurance broker fees | 32 | | Insurance broker organization code? | 3 |
|
| PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 ) |
| Policy contract number | 0012708549 |
| Policy instance | 8 |
| Insurance contract or identification number | 0012708549 | | Number of Individuals Covered | 98 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $1,280 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | WHOLE LIFE | | Welfare Benefit Premiums Paid to Carrier | USD $25,592 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,280 | | Insurance broker organization code? | 3 |
|
| PAUL REVERE VARIABLE ANNUITY INS. CO. (National Association of Insurance Commissioners NAIC id number: 67601 ) |
| Policy contract number | 682820 |
| Policy instance | 9 |
| Insurance contract or identification number | 682820 | | Number of Individuals Covered | 164 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $3,924 | | Total amount of fees paid to insurance company | USD $691 | | Other welfare benefits provided | GRP ACCIDENT | | Welfare Benefit Premiums Paid to Carrier | USD $40,346 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,924 | | Amount paid for insurance broker fees | 691 | | Additional information about fees paid to insurance broker | GENERAL FEES | | Insurance broker organization code? | 3 |
|
| PAUL REVERE VARIABLE ANNUITY INS. CO. (National Association of Insurance Commissioners NAIC id number: 67601 ) |
| Policy contract number | 682819 |
| Policy instance | 10 |
| Insurance contract or identification number | 682819 | | Number of Individuals Covered | 220 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $13,218 | | Total amount of fees paid to insurance company | USD $1,284 | | Other welfare benefits provided | CRITICAL ILLNESS | | Welfare Benefit Premiums Paid to Carrier | USD $88,118 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $13,218 | | Amount paid for insurance broker fees | 1284 | | Additional information about fees paid to insurance broker | GENERAL FEES | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | R0797290 |
| Policy instance | 6 |
| Insurance contract or identification number | R0797290 | | Number of Individuals Covered | 3 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $93 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | GCIEE GRPACCVOEN | | Welfare Benefit Premiums Paid to Carrier | USD $1,075 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $93 | | Insurance broker organization code? | 3 |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 30022396 |
| Policy instance | 1 |
| Insurance contract or identification number | 30022396 | | Number of Individuals Covered | 1234 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $2,611 | | Total amount of fees paid to insurance company | USD $81 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $304,597 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,611 | | Amount paid for insurance broker fees | 81 | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | 02301C |
| Policy instance | 5 |
| Insurance contract or identification number | 02301C | | Number of Individuals Covered | 2 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $216 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ADD | | Welfare Benefit Premiums Paid to Carrier | USD $2,155 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $216 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 469869 |
| Policy instance | 3 |
| Insurance contract or identification number | 469869 | | Number of Individuals Covered | 1403 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $16,624 | | Total amount of fees paid to insurance company | USD $12,476 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ADD | | Welfare Benefit Premiums Paid to Carrier | USD $880,744 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $16,624 | | Amount paid for insurance broker fees | 12476 | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 469871 |
| Policy instance | 2 |
| Insurance contract or identification number | 469871 | | Number of Individuals Covered | 572 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $53,775 | | Total amount of fees paid to insurance company | USD $4,887 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ADD | | Welfare Benefit Premiums Paid to Carrier | USD $382,878 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $53,775 | | Amount paid for insurance broker fees | 4887 | | Insurance broker organization code? | 3 |
|
| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
| Policy contract number | 02301C |
| Policy instance | 6 |
| Insurance contract or identification number | 02301C | | Number of Individuals Covered | 2 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $4,427 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Other welfare benefits provided | MEDICAL EVACUATION | | Welfare Benefit Premiums Paid to Carrier | USD $44,271 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,427 |
|
| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
| Policy contract number | 02301A |
| Policy instance | 7 |
| Insurance contract or identification number | 02301A | | Number of Individuals Covered | 1 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | MBA | | Welfare Benefit Premiums Paid to Carrier | USD $40,800 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | R0797290 |
| Policy instance | 8 |
| Insurance contract or identification number | R0797290 | | Number of Individuals Covered | 461 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $45,150 | | Total amount of fees paid to insurance company | USD $7,548 | | Other welfare benefits provided | GCIEE GRPACCVOEN | | Welfare Benefit Premiums Paid to Carrier | USD $79,480 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $45,150 | | Amount paid for insurance broker fees | 7548 | | Insurance broker organization code? | 3 |
|
| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
| Policy contract number | 3339660 |
| Policy instance | 4 |
| Insurance contract or identification number | 3339660 | | Number of Individuals Covered | 2790 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $148,696 | | Total amount of fees paid to insurance company | USD $45,122 | | Welfare Benefit Premiums Paid to Carrier | USD $1,641,296 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $120,379 | | Amount paid for insurance broker fees | 45122 | | Insurance broker organization code? | 3 |
|
| PAUL REVERE VARIABLE ANNUITY INS. CO. (National Association of Insurance Commissioners NAIC id number: 67601 ) |
| Policy contract number | 682819 |
| Policy instance | 12 |
| Insurance contract or identification number | 682819 | | Number of Individuals Covered | 179 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $6,932 | | Total amount of fees paid to insurance company | USD $1,155 | | Other welfare benefits provided | CRITICAL ILLNESS | | Welfare Benefit Premiums Paid to Carrier | USD $60,780 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,932 | | Amount paid for insurance broker fees | 1155 | | Insurance broker organization code? | 3 |
|
| PAUL REVERE VARIABLE ANNUITY INS. CO. (National Association of Insurance Commissioners NAIC id number: 67601 ) |
| Policy contract number | 682820 |
| Policy instance | 11 |
| Insurance contract or identification number | 682820 | | Number of Individuals Covered | 122 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $1,899 | | Total amount of fees paid to insurance company | USD $417 | | Other welfare benefits provided | GRP ACCIDENT | | Welfare Benefit Premiums Paid to Carrier | USD $27,007 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,899 | | Amount paid for insurance broker fees | 417 | | Insurance broker organization code? | 3 |
|
| PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 ) |
| Policy contract number | 0012708549 |
| Policy instance | 10 |
| Insurance contract or identification number | 0012708549 | | Number of Individuals Covered | 106 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $17,472 | | Total amount of fees paid to insurance company | USD $2,072 | | Other welfare benefits provided | WHOLE LIFE | | Welfare Benefit Premiums Paid to Carrier | USD $46,130 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $14,029 | | Amount paid for insurance broker fees | 2072 | | Insurance broker organization code? | 3 |
|
| FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 ) |
| Policy contract number | 699685 |
| Policy instance | 9 |
| Insurance contract or identification number | 699685 | | Number of Individuals Covered | 6 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $233 | | Total amount of fees paid to insurance company | USD $20 | | Other welfare benefits provided | DBL | | Welfare Benefit Premiums Paid to Carrier | USD $1,511 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $233 | | Amount paid for insurance broker fees | 20 |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 30022396 |
| Policy instance | 1 |
| Insurance contract or identification number | 30022396 | | Number of Individuals Covered | 1225 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $4,887 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $318,560 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,887 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 469871 |
| Policy instance | 2 |
| Insurance contract or identification number | 469871 | | Number of Individuals Covered | 635 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $54,619 | | Total amount of fees paid to insurance company | USD $4,552 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ADD | | Welfare Benefit Premiums Paid to Carrier | USD $372,766 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $54,619 | | Amount paid for insurance broker fees | 4552 | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 469869 |
| Policy instance | 3 |
| Insurance contract or identification number | 469869 | | Number of Individuals Covered | 1410 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $9,957 | | Total amount of fees paid to insurance company | USD $7,514 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ADD | | Welfare Benefit Premiums Paid to Carrier | USD $719,688 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $9,957 | | Amount paid for insurance broker fees | 7514 |
|
| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
| Policy contract number | 3339660 |
| Policy instance | 4 |
| Insurance contract or identification number | 3339660 | | Number of Individuals Covered | 2792 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $149,090 | | Total amount of fees paid to insurance company | USD $0 | | Welfare Benefit Premiums Paid to Carrier | USD $1,476,539 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $149,090 | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | 02301C |
| Policy instance | 5 |
| Insurance contract or identification number | 02301C | | Number of Individuals Covered | 3 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $213 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ADD | | Welfare Benefit Premiums Paid to Carrier | USD $2,149 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $213 |
|
| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
| Policy contract number | 02301C |
| Policy instance | 6 |
| Insurance contract or identification number | 02301C | | Number of Individuals Covered | 3 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $4,370 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Other welfare benefits provided | MEDICAL EVACUATION | | Welfare Benefit Premiums Paid to Carrier | USD $47,900 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,370 |
|
| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
| Policy contract number | 02301A |
| Policy instance | 7 |
| Insurance contract or identification number | 02301A | | Number of Individuals Covered | 2 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | MBA | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | R0797290 |
| Policy instance | 8 |
| Insurance contract or identification number | R0797290 | | Number of Individuals Covered | 494 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $35,164 | | Total amount of fees paid to insurance company | USD $5,988 | | Other welfare benefits provided | GCIEE GRPACCVOEN | | Welfare Benefit Premiums Paid to Carrier | USD $54,784 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $35,164 | | Amount paid for insurance broker fees | 5988 |
|
| FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 ) |
| Policy contract number | R0797290 |
| Policy instance | 9 |
| Insurance contract or identification number | R0797290 | | Number of Individuals Covered | 1 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $18 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | WHOLE LIFE | | Welfare Benefit Premiums Paid to Carrier | USD $22 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $18 |
|
| FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 ) |
| Policy contract number | 699685 |
| Policy instance | 10 |
| Insurance contract or identification number | 699685 | | Number of Individuals Covered | 6 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $180 | | Total amount of fees paid to insurance company | USD $15 | | Other welfare benefits provided | DBL | | Welfare Benefit Premiums Paid to Carrier | USD $1,134 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $180 | | Amount paid for insurance broker fees | 15 |
|
| PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 ) |
| Policy contract number | 0012708549 |
| Policy instance | 11 |
| Insurance contract or identification number | 0012708549 | | Number of Individuals Covered | 108 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $11,506 | | Total amount of fees paid to insurance company | USD $1,479 | | Other welfare benefits provided | WHOLE LIFE | | Welfare Benefit Premiums Paid to Carrier | USD $13,536 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $9,574 | | Amount paid for insurance broker fees | 1479 |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 30022396 |
| Policy instance | 1 |
| Insurance contract or identification number | 30022396 | | Number of Individuals Covered | 1265 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | 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 $200,114 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 469871 |
| Policy instance | 2 |
| Insurance contract or identification number | 469871 | | Number of Individuals Covered | 619 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $68,996 | | Total amount of fees paid to insurance company | USD $5,750 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ADD | | Welfare Benefit Premiums Paid to Carrier | USD $459,476 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $68,996 | | Amount paid for insurance broker fees | 5750 | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 469869 |
| Policy instance | 3 |
| Insurance contract or identification number | 469869 | | Number of Individuals Covered | 1433 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $16,609 | | Total amount of fees paid to insurance company | USD $11,987 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ADD | | Welfare Benefit Premiums Paid to Carrier | USD $819,388 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $16,609 | | Amount paid for insurance broker fees | 11987 |
|
| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
| Policy contract number | 3339660 |
| Policy instance | 4 |
| Insurance contract or identification number | 3339660 | | Number of Individuals Covered | 2915 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $145,350 | | Total amount of fees paid to insurance company | USD $0 | | Welfare Benefit Premiums Paid to Carrier | USD $1,320,811 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $145,350 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | 02301C |
| Policy instance | 5 |
| Insurance contract or identification number | 02301C | | Number of Individuals Covered | 3 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $271 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ADD | | Welfare Benefit Premiums Paid to Carrier | USD $2,711 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $271 |
|
| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
| Policy contract number | 02301A |
| Policy instance | 7 |
| Insurance contract or identification number | 02301A | | Number of Individuals Covered | 1 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $1,632 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | MBA | | Welfare Benefit Premiums Paid to Carrier | USD $20,400 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,632 |
|
| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
| Policy contract number | 02301C |
| Policy instance | 6 |
| Insurance contract or identification number | 02301C | | Number of Individuals Covered | 3 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $4,958 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Other welfare benefits provided | MEDICAL EVACUATION | | Welfare Benefit Premiums Paid to Carrier | USD $49,580 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,958 |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 30022396 |
| Policy instance | 1 |
| Insurance contract or identification number | 30022396 | | Number of Individuals Covered | 1294 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | 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 $180,763 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 469871 |
| Policy instance | 2 |
| Insurance contract or identification number | 469871 | | Number of Individuals Covered | 460 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $62,820 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ADD | | Welfare Benefit Premiums Paid to Carrier | USD $423,515 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $62,820 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 469869 |
| Policy instance | 3 |
| Insurance contract or identification number | 469869 | | Number of Individuals Covered | 1282 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $21,607 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ADD | | Welfare Benefit Premiums Paid to Carrier | USD $894,010 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $21,607 |
|
| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
| Policy contract number | 3339660 |
| Policy instance | 4 |
| Insurance contract or identification number | 3339660 | | Number of Individuals Covered | 3054 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $138,539 | | Total amount of fees paid to insurance company | USD $0 | | Welfare Benefit Premiums Paid to Carrier | USD $1,259,419 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $138,539 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | 2301C |
| Policy instance | 5 |
| Insurance contract or identification number | 2301C | | Number of Individuals Covered | 5 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $337 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ADD | | Welfare Benefit Premiums Paid to Carrier | USD $2,592 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $337 | | Insurance broker organization code? | 3 |
|
| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
| Policy contract number | 02301C |
| Policy instance | 6 |
| Insurance contract or identification number | 02301C | | Number of Individuals Covered | 5 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $5,528 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Other welfare benefits provided | MEDICAL EVACUATION | | Welfare Benefit Premiums Paid to Carrier | USD $50,833 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,528 | | Insurance broker organization code? | 3 |
|
| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
| Policy contract number | 02301C |
| Policy instance | 8 |
| Insurance contract or identification number | 02301C | | Number of Individuals Covered | 5 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $1,968 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Other welfare benefits provided | MEDICAL EVACUATION | | Welfare Benefit Premiums Paid to Carrier | USD $24,123 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,968 | | Insurance broker name | HICKOCK & BOARDMAN |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | 2301C |
| Policy instance | 7 |
| Insurance contract or identification number | 2301C | | Number of Individuals Covered | 5 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $354 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ADD | | Welfare Benefit Premiums Paid to Carrier | USD $4,321 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $354 | | Insurance broker name | HICKOCK & BOARDMAN |
|
| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
| Policy contract number | 3339660 |
| Policy instance | 6 |
| Insurance contract or identification number | 3339660 | | Number of Individuals Covered | 3152 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $123,038 | | Total amount of fees paid to insurance company | USD $0 | | Welfare Benefit Premiums Paid to Carrier | USD $1,050,205 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $123,038 | | Insurance broker organization code? | 3 | | Insurance broker name | HICKOK&BOARDMAN FIN PLNG &GRP 1 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 469906 |
| Policy instance | 5 |
| Insurance contract or identification number | 469906 | | Number of Individuals Covered | 1277 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $23,593 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Insurance broker organization code? | 3 | | Insurance broker name | HICKOK&BOARDMAN FIN PLNG &GRP 1 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 469869 |
| Policy instance | 4 |
| Insurance contract or identification number | 469869 | | Number of Individuals Covered | 1277 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $13,957 | | Total amount of fees paid to insurance company | USD $14,191 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ADD | | Welfare Benefit Premiums Paid to Carrier | USD $743,156 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $13,957 | | Amount paid for insurance broker fees | 14191 | | Insurance broker name | PROSENTIAL GROUP LLC |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 469871 |
| Policy instance | 3 |
| Insurance contract or identification number | 469871 | | Number of Individuals Covered | 616 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $57,140 | | Total amount of fees paid to insurance company | USD $6,666 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ADD | | Welfare Benefit Premiums Paid to Carrier | USD $352,424 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $57,140 | | Amount paid for insurance broker fees | 6666 | | Insurance broker name | PROSENTIAL GROUP LLC |
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| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 30022396 |
| Policy instance | 2 |
| Insurance contract or identification number | 30022396 | | Number of Individuals Covered | 1426 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | 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 $179,763 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Insurance broker organization code? | 3 | | Insurance broker name | HICKOCK & BOARDMAN FINANCIAL PL |
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| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
| Policy contract number | 02301A |
| Policy instance | 1 |
| Insurance contract or identification number | 02301A | | Number of Individuals Covered | 1 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $1,632 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $20,400 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,632 | | Insurance broker name | HICKOK & BOARDMAN |
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| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
| Policy contract number | 02301A |
| Policy instance | 6 |
| Insurance contract or identification number | 02301A | | Number of Individuals Covered | 1 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $471 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $5,890 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 471 | | Insurance broker organization code? | 3 | | Insurance broker name | HICKOK&BOARDMAN FIN PLNG &GRP 1 |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 30022396 |
| Policy instance | 7 |
| Insurance contract or identification number | 30022396 | | Number of Individuals Covered | 1420 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $32,944 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $173,392 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 32944 | | Insurance broker organization code? | 3 | | Insurance broker name | HICKOK&BOARDMAN FIN PLNG &GRP 1 |
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| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
| Policy contract number | 02301B |
| Policy instance | 8 |
| Insurance contract or identification number | 02301B | | Number of Individuals Covered | 5 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $4,499 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Other welfare benefits provided | EVACUATION | | Welfare Benefit Premiums Paid to Carrier | USD $48,958 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,499 | | Insurance broker organization code? | 3 | | 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 | | 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 | | Insurance broker name | HICKOK&BOARDMAN FIN PLNG &GRP 1 |
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| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | 02301B |
| Policy instance | 13 |
| Insurance contract or identification number | 02301B | | Number of Individuals Covered | 5 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $534 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $6,035 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $534 | | Insurance broker organization code? | 3 | | Insurance broker name | HICKOK&BOARDMAN FIN PLNG &GRP 1 |
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| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | 02301B |
| Policy instance | 12 |
| Insurance contract or identification number | 02301B | | Number of Individuals Covered | 5 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $534 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $6,036 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $534 | | Insurance broker name | HICKOK&BOARDMAN FIN PLNG &GRP 1 |
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| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 71412 ) |
| Policy contract number | T66BA-P-051817 |
| Policy instance | 11 |
| Insurance contract or identification number | T66BA-P-051817 | | Number of Individuals Covered | 696 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $5,493 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $36,617 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,493 | | Insurance broker name | MUTUTAL OF OMAHA INSURANCE COMPANY |
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| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 469869 |
| Policy instance | 10 |
| Insurance contract or identification number | 469869 | | Number of Individuals Covered | 1489 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $9,127 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $143,842 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $9,127 | | Insurance broker name | HICKOK&BOARDMAN FIN PLNG &GRP 1 |
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| GERBER LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70939 ) |
| Policy contract number | |
| Policy instance | 5 |
| Number of Individuals Covered | 1372 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $671,288 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $861,532 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 561062 | | Insurance broker organization code? | 5 | | Insurance broker name | HICKOK&BOARDMAN FINANCIAL |
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| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLTDOADY1 |
| Policy instance | 3 |
| Insurance contract or identification number | GLTDOADY1 | | Number of Individuals Covered | 1460 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $36,106 | | Total amount of fees paid to insurance company | USD $0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $361,061 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $36,106 | | Insurance broker organization code? | 3 | | Insurance broker name | HICKOK&BOARDMAN FIN PLNG &GRP 1 |
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| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GVTLOADY1 |
| Policy instance | 4 |
| Insurance contract or identification number | GVTLOADY1 | | Number of Individuals Covered | 593 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $36,038 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $240,257 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $36,038 | | Insurance broker organization code? | 3 | | Insurance broker name | HICKOK&BOARDMAN FIN PLNG &GRP 1 |
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| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | |
| Policy instance | 9 |
| Number of Individuals Covered | 823 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $14,177 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $91,128 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $14,177 | | Insurance broker name | HICKOK&BOARDMAN FIN PLNG &GRP 1 |
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| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUGOADY1 |
| Policy instance | 2 |
| Insurance contract or identification number | GLUGOADY1 | | Number of Individuals Covered | 1460 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $23,459 | | 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 $234,591 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $23,459 | | Insurance broker organization code? | 3 | | Insurance broker name | HICKOK&BOARDMAN FIN PLNG &GRP 1 |
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| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUSIBADY1 |
| Policy instance | 1 |
| Insurance contract or identification number | GUSIBADY1 | | Number of Individuals Covered | 965 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $1,480 | | Total amount of fees paid to insurance company | USD $13,318 | | Other welfare benefits provided | ADMINISTRATIVE SERVICES | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,480 | | Amount paid for insurance broker fees | 13318 | | Insurance broker organization code? | 3 | | Insurance broker name | HICKOK&BOARDMAN FIN PLNG &GRP 1 |
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| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | 02301B |
| Policy instance | 9 |
| Insurance contract or identification number | 02301B | | Number of Individuals Covered | 6 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $1,528 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Welfare Benefit Premiums Paid to Carrier | USD $13,926 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,528 | | Additional information about fees paid to insurance broker | SALES AND SERVICE | | Insurance broker organization code? | 3 | | Insurance broker name | HICKOK&BOARDMAN FIN PLNG &GRP 1 |
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| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
| Policy contract number | 02301B |
| Policy instance | 8 |
| Insurance contract or identification number | 02301B | | Number of Individuals Covered | 6 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $8,387 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Other welfare benefits provided | EVACUATION | | Welfare Benefit Premiums Paid to Carrier | USD $76,643 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,387 | | Additional information about fees paid to insurance broker | SALES AND SERVICE | | Insurance broker organization code? | 3 | | Insurance broker name | HICKOK&BOARDMAN FIN PLNG &GRP 1 |
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| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 30022396 |
| Policy instance | 7 |
| Insurance contract or identification number | 30022396 | | Number of Individuals Covered | 1345 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $31,346 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $164,981 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 31346 | | Additional information about fees paid to insurance broker | AGENT OR BROKER OF RECORD | | Insurance broker organization code? | 3 | | Insurance broker name | HICKOK&BOARDMAN FIN PLNG &GRP 1 |
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| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
| Policy contract number | 02301A |
| Policy instance | 6 |
| Insurance contract or identification number | 02301A | | Number of Individuals Covered | 1 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $471 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $5,890 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $471 | | Additional information about fees paid to insurance broker | SALES & SERVICE | | Insurance broker organization code? | 3 | | Insurance broker name | HICKOK&BOARDMAN FIN PLNG &GRP 1 |
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| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLTDOADY1 |
| Policy instance | 3 |
| Insurance contract or identification number | GLTDOADY1 | | Number of Individuals Covered | 1433 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $37,227 | | Total amount of fees paid to insurance company | USD $15,685 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $372,270 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $37,227 | | Amount paid for insurance broker fees | 15685 | | Additional information about fees paid to insurance broker | AGENT OR BROKER OF RECORD | | Insurance broker organization code? | 3 | | Insurance broker name | HICKOK&BOARDMAN FIN PLNG &GRP 1 |
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| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUSIBADY1 |
| Policy instance | 1 |
| Insurance contract or identification number | GUSIBADY1 | | Number of Individuals Covered | 970 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $1,941 | | Total amount of fees paid to insurance company | USD $17,474 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Other welfare benefits provided | ADMINISTRATIVE SERVICES | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,941 | | Amount paid for insurance broker fees | 17474 | | Additional information about fees paid to insurance broker | AGENT OR BROKER OF RECORD | | Insurance broker organization code? | 3 | | Insurance broker name | HICKOK&BOARDMAN FIN PLNG &GRP 1 |
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| GERBER LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70939 ) |
| Policy contract number | |
| Policy instance | 5 |
| Number of Individuals Covered | 1316 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $624,419 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $753,880 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 519664 | | Additional information about fees paid to insurance broker | CONTRACT ADMINISTRATOR | | Insurance broker organization code? | 5 | | Insurance broker name | HICKOK&BOARDMAN FINANCIAL |
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| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GVTLOADY1 |
| Policy instance | 4 |
| Insurance contract or identification number | GVTLOADY1 | | Number of Individuals Covered | 572 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $45,244 | | Total amount of fees paid to insurance company | USD $11,803 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $301,626 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $45,244 | | Amount paid for insurance broker fees | 11803 | | Additional information about fees paid to insurance broker | AGENT OR BROKER OF RECORD | | Insurance broker organization code? | 3 | | Insurance broker name | HICKOK&BOARDMAN FIN PLNG &GRP 1 |
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| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUGOADY1 |
| Policy instance | 2 |
| Insurance contract or identification number | GLUGOADY1 | | Number of Individuals Covered | 1433 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $28,323 | | Total amount of fees paid to insurance company | USD $13,358 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $283,225 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $28,323 | | Amount paid for insurance broker fees | 13358 | | Additional information about fees paid to insurance broker | AGENT OR BROKER OF RECORD | | Insurance broker organization code? | 3 | | Insurance broker name | HICKOK&BOARDMAN FIN PLNG &GRP 1 |
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| CIGNA HEALTH AND LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 67369 ) |
| Policy contract number | 02301A |
| Policy instance | 9 |
| Insurance contract or identification number | 02301A | | Number of Individuals Covered | 1 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $471 | | 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 | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $5,890 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $471 | | Additional information about fees paid to insurance broker | SALES & SERVICES | | Insurance broker organization code? | 3 | | Insurance broker name | HICKOK & BOARDMAN FIN PLNG & GRP 1 |
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| CIGNA HEALTH AND LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 67369 ) |
| Policy contract number | 02301B |
| Policy instance | 8 |
| Insurance contract or identification number | 02301B | | Number of Individuals Covered | 8 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $3,616 | | 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 | Yes | | 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 | | Other welfare benefits provided | EVACUATION COVERAGE | | 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 $43,388 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,616 | | Additional information about fees paid to insurance broker | SALES & SERVICES | | Insurance broker organization code? | 3 | | Insurance broker name | HICKOK & BOARDMAN FIN PLNG & GRP 1 |
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| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG0ADY1 |
| Policy instance | 2 |
| Insurance contract or identification number | GLUG0ADY1 | | Number of Individuals Covered | 1407 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $26,877 | | 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 | 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 $268,770 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $26,877 | | Additional information about fees paid to insurance broker | AGENT OR BROKER OF RECORD | | Insurance broker organization code? | 3 | | Insurance broker name | HICKOK & BOARDMAN FIN PLNG & GRP 1 |
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| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLTD0ADY1 |
| Policy instance | 3 |
| Insurance contract or identification number | GLTD0ADY1 | | Number of Individuals Covered | 1407 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $35,424 | | 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 $354,241 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $35,424 | | Additional information about fees paid to insurance broker | AGENT OR BROKER OF RECORD | | Insurance broker organization code? | 3 | | Insurance broker name | HICKOK & BOARDMAN FIN PLNG & GRP 1 |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 30022396 |
| Policy instance | 4 |
| Insurance contract or identification number | 30022396 | | Number of Individuals Covered | 1304 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of fees paid to insurance company | USD $23,476 | | 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 $138,092 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 23476 | | Additional information about fees paid to insurance broker | AGENT OR BROKER OF RECORD | | Insurance broker organization code? | 3 | | Insurance broker name | HICKOK & BOARDMAN FIN PLNG & GRP 1 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | 02301B |
| Policy instance | 10 |
| Insurance contract or identification number | 02301B | | Number of Individuals Covered | 8 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $618 | | 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 | Yes | | 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 $7,532 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $618 | | Additional information about fees paid to insurance broker | SALES & SERVICES | | Insurance broker organization code? | 3 | | Insurance broker name | HICKOK & BOARDMAN FIN PLNG & GRP 1 |
|
| CIGNA WORLDWIDE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62308 ) |
| Policy contract number | 02301B |
| Policy instance | 6 |
| Insurance contract or identification number | 02301B | | Number of Individuals Covered | 8 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $244 | | 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 $2,443 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $244 | | Additional information about fees paid to insurance broker | SALES & SERVICES | | Insurance broker organization code? | 3 | | Insurance broker name | HICKOK & BOARDMAN FIN PLNG & GRP 1 |
|
| CONNECTICUT GENERAL LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 62308 ) |
| Policy contract number | 02301B |
| Policy instance | 7 |
| Insurance contract or identification number | 02301B | | Number of Individuals Covered | 8 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $4,396 | | 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 | Yes | | Dental Insurance Welfare Benefit | Yes | | 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 AND EVACUATION COVERAGE | | 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 $43,960 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,396 | | Additional information about fees paid to insurance broker | SALES & SERVICES | | Insurance broker organization code? | 3 | | Insurance broker name | HICKOK & BOARDMAN FIN PLNG & GRP 1 |
|
| GERBER LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70939 ) |
| Policy contract number | 0 |
| Policy instance | 5 |
| Insurance contract or identification number | 0 | | Number of Individuals Covered | 1280 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of fees paid to insurance company | USD $610,222 | | 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 | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $725,730 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 101942 | | Additional information about fees paid to insurance broker | BROKER | | Insurance broker organization code? | 3 | | Insurance broker name | CBA BLUE |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GVTL0ADY1 |
| Policy instance | 1 |
| Insurance contract or identification number | GVTL0ADY1 | | Number of Individuals Covered | 561 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $39,818 | | 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 | | 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 $265,452 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $39,818 | | Additional information about fees paid to insurance broker | AGENT OR BROKER OF RECORD | | Insurance broker organization code? | 3 | | Insurance broker name | HICKOK & BOARDMAN FIN PLNG & GRP 1 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GVTL0ADY1 |
| Policy instance | 1 |
| Insurance contract or identification number | GVTL0ADY1 | | Number of Individuals Covered | 548 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $37,210 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $248,064 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $37,210 | | Additional information about fees paid to insurance broker | AGENT OR BROKER OF RECORD | | Insurance broker organization code? | 3 | | Insurance broker name | HICKOK & BOARDMAN FIN PLNG & GRP I |
|
| CONNECTICUT GENERAL LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 62308 ) |
| Policy contract number | 02301B |
| Policy instance | 7 |
| Insurance contract or identification number | 02301B | | Number of Individuals Covered | 7 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $10,396 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D AND EVACUATION COVERAGE | | Welfare Benefit Premiums Paid to Carrier | USD $103,964 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $10,396 | | Additional information about fees paid to insurance broker | SALES & SERVICES | | Insurance broker organization code? | 3 | | Insurance broker name | HICKOK & BOARDMAN |
|
| CIGNA WORLDWIDE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62308 ) |
| Policy contract number | 02301B |
| Policy instance | 6 |
| Insurance contract or identification number | 02301B | | Number of Individuals Covered | 8 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $592 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $5,922 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $592 | | Additional information about fees paid to insurance broker | SALES & SERVICES | | Insurance broker organization code? | 3 | | Insurance broker name | HICKOK & BOARDMAN |
|
| GERBER LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70939 ) |
| Policy contract number | 0 |
| Policy instance | 5 |
| Insurance contract or identification number | 0 | | Number of Individuals Covered | 1391 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Total amount of fees paid to insurance company | USD $619,604 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $623,831 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 519727 | | Additional information about fees paid to insurance broker | CONTRACT ADMINISTRATION | | Insurance broker organization code? | 5 | | Insurance broker name | HICKOK & BOARDMAN FINANCIAL |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 30022396 |
| Policy instance | 4 |
| Insurance contract or identification number | 30022396 | | Number of Individuals Covered | 1237 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $142,104 | | 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 | GLTD0ADY1 |
| Policy instance | 3 |
| Insurance contract or identification number | GLTD0ADY1 | | Number of Individuals Covered | 1365 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $30,999 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $309,994 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $30,999 | | Additional information about fees paid to insurance broker | AGENT OR BROKER OF RECORD | | Insurance broker organization code? | 3 | | Insurance broker name | HICKOK & BOARDMAN FIN PLNG & GRP I |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG0ADY1 |
| Policy instance | 2 |
| Insurance contract or identification number | GLUG0ADY1 | | Number of Individuals Covered | 1365 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $22,336 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $223,363 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $22,336 | | Additional information about fees paid to insurance broker | AGENT OR BROKER OF RECORD | | Insurance broker organization code? | 3 | | Insurance broker name | HICKOK & BOARDMAN FIN PLNG & GRP I |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GVTL0ADY1 |
| Policy instance | 6 |
| Insurance contract or identification number | GVTL0ADY1 | | Number of Individuals Covered | 533 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2011-12-31 | | Total amount of commissions paid to insurance broker | USD $38,827 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $227,023 | | 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 | GLUG0ADY1 |
| Policy instance | 5 |
| Insurance contract or identification number | GLUG0ADY1 | | Number of Individuals Covered | 1340 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2011-12-31 | | Total amount of commissions paid to insurance broker | USD $25,684 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $209,154 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 30022396 |
| Policy instance | 4 |
| Insurance contract or identification number | 30022396 | | Number of Individuals Covered | 1188 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2011-12-31 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $135,322 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| GERBER LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70939 ) |
| Policy contract number | |
| Policy instance | 3 |
| Number of Individuals Covered | 1263 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2011-12-31 | | Total amount of fees paid to insurance company | USD $601,895 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $494,788 | | 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 | GLTD0ADY1 |
| Policy instance | 7 |
| Insurance contract or identification number | GLTD0ADY1 | | Number of Individuals Covered | 1340 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2011-12-31 | | Total amount of commissions paid to insurance broker | USD $34,588 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $289,627 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| CONNECTICUT GENERAL LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 62308 ) |
| Policy contract number | 02301B |
| Policy instance | 1 |
| Insurance contract or identification number | 02301B | | Number of Individuals Covered | 6 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2011-12-31 | | Total amount of commissions paid to insurance broker | USD $4,356 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D AND EVACUATION COVERAGE | | Welfare Benefit Premiums Paid to Carrier | USD $43,559 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| CIGNA WORLDWIDE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62308 ) |
| Policy contract number | 02301B |
| Policy instance | 2 |
| Insurance contract or identification number | 02301B | | Number of Individuals Covered | 7 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2011-12-31 | | Total amount of commissions paid to insurance broker | USD $246 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $2,419 | | 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 | GLUG0ADY1 |
| Policy instance | 5 |
| Insurance contract or identification number | GLUG0ADY1 | | Number of Individuals Covered | 1330 | | Insurance policy start date | 2010-01-01 | | Insurance policy end date | 2011-01-01 | | Total amount of commissions paid to insurance broker | USD $20,980 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $208,899 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 117873 |
| Policy instance | 6 |
| Insurance contract or identification number | 117873 | | Number of Individuals Covered | 0 | | Insurance policy start date | 2010-01-01 | | Insurance policy end date | 2011-01-01 | | Total amount of commissions paid to insurance broker | USD $4,751 | | Total amount of fees paid to insurance company | USD $475 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $47,510 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| UNIMERICA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 3086 ) |
| Policy contract number | 0 |
| Policy instance | 3 |
| Insurance contract or identification number | 0 | | Number of Individuals Covered | 1266 | | Insurance policy start date | 2010-01-01 | | Insurance policy end date | 2010-12-31 | | Total amount of fees paid to insurance company | USD $491,383 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $384,669 | | 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 | GLTD0ADY1 |
| Policy instance | 2 |
| Insurance contract or identification number | GLTD0ADY1 | | Number of Individuals Covered | 1330 | | Insurance policy start date | 2010-01-01 | | Insurance policy end date | 2011-01-01 | | Total amount of commissions paid to insurance broker | USD $28,809 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $288,091 | | 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 | GVTL0ADY1 |
| Policy instance | 1 |
| Insurance contract or identification number | GVTL0ADY1 | | Number of Individuals Covered | 514 | | Insurance policy start date | 2010-01-01 | | Insurance policy end date | 2011-01-01 | | Total amount of commissions paid to insurance broker | USD $32,000 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $213,335 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 152196 |
| Policy instance | 4 |
| Insurance contract or identification number | 152196 | | Number of Individuals Covered | 0 | | Insurance policy start date | 2010-01-01 | | Insurance policy end date | 2011-01-01 | | Total amount of commissions paid to insurance broker | USD $2,324 | | Total amount of fees paid to insurance company | USD $155 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $15,492 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
