COUNSELING SERVICE OF ADDISON COUNTY, INC. has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan COUNSELING SERVICE OF ADDISON COUNTY, INC. EMPLOYEE BENEFIT PLAN
401k plan membership statisitcs for COUNSELING SERVICE OF ADDISON COUNTY, INC. EMPLOYEE BENEFIT PLAN
| Measure | Date | Value |
|---|
| 2021: COUNSELING SERVICE OF ADDISON COUNTY, INC. EMPLOYEE BENEFIT PLAN 2021 401k membership |
|---|
| Total participants, beginning-of-year | 2021-11-01 | 241 |
| Total number of active participants reported on line 7a of the Form 5500 | 2021-11-01 | 231 |
| Number of retired or separated participants receiving benefits | 2021-11-01 | 2 |
| Number of other retired or separated participants entitled to future benefits | 2021-11-01 | 0 |
| Total of all active and inactive participants | 2021-11-01 | 233 |
| Number of employers contributing to the scheme | 2021-11-01 | 0 |
| 2020: COUNSELING SERVICE OF ADDISON COUNTY, INC. EMPLOYEE BENEFIT PLAN 2020 401k membership |
|---|
| Total participants, beginning-of-year | 2020-11-01 | 251 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-11-01 | 237 |
| Number of retired or separated participants receiving benefits | 2020-11-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2020-11-01 | 0 |
| Total of all active and inactive participants | 2020-11-01 | 237 |
| Number of employers contributing to the scheme | 2020-11-01 | 0 |
| Total participants, beginning-of-year | 2020-10-01 | 250 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-10-01 | 248 |
| Number of retired or separated participants receiving benefits | 2020-10-01 | 3 |
| Number of other retired or separated participants entitled to future benefits | 2020-10-01 | 0 |
| Total of all active and inactive participants | 2020-10-01 | 251 |
| Number of employers contributing to the scheme | 2020-10-01 | 0 |
| 2019: COUNSELING SERVICE OF ADDISON COUNTY, INC. EMPLOYEE BENEFIT PLAN 2019 401k membership |
|---|
| Total participants, beginning-of-year | 2019-10-01 | 298 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-10-01 | 267 |
| Number of retired or separated participants receiving benefits | 2019-10-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2019-10-01 | 0 |
| Total of all active and inactive participants | 2019-10-01 | 267 |
| Number of employers contributing to the scheme | 2019-10-01 | 0 |
| 2018: COUNSELING SERVICE OF ADDISON COUNTY, INC. EMPLOYEE BENEFIT PLAN 2018 401k membership |
|---|
| Total participants, beginning-of-year | 2018-10-01 | 299 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-10-01 | 298 |
| Number of retired or separated participants receiving benefits | 2018-10-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2018-10-01 | 0 |
| Total of all active and inactive participants | 2018-10-01 | 298 |
| Number of employers contributing to the scheme | 2018-10-01 | 0 |
| 2017: COUNSELING SERVICE OF ADDISON COUNTY, INC. EMPLOYEE BENEFIT PLAN 2017 401k membership |
|---|
| Total participants, beginning-of-year | 2017-10-01 | 306 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-10-01 | 299 |
| Number of retired or separated participants receiving benefits | 2017-10-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2017-10-01 | 0 |
| Total of all active and inactive participants | 2017-10-01 | 299 |
| Number of employers contributing to the scheme | 2017-10-01 | 0 |
| 2016: COUNSELING SERVICE OF ADDISON COUNTY, INC. EMPLOYEE BENEFIT PLAN 2016 401k membership |
|---|
| Total participants, beginning-of-year | 2016-10-01 | 303 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-10-01 | 306 |
| Number of retired or separated participants receiving benefits | 2016-10-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2016-10-01 | 0 |
| Total of all active and inactive participants | 2016-10-01 | 306 |
| Number of employers contributing to the scheme | 2016-10-01 | 0 |
| 2015: COUNSELING SERVICE OF ADDISON COUNTY, INC. EMPLOYEE BENEFIT PLAN 2015 401k membership |
|---|
| Total participants, beginning-of-year | 2015-10-01 | 379 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-10-01 | 303 |
| Number of retired or separated participants receiving benefits | 2015-10-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2015-10-01 | 0 |
| Total of all active and inactive participants | 2015-10-01 | 303 |
| Number of employers contributing to the scheme | 2015-10-01 | 0 |
| 2014: COUNSELING SERVICE OF ADDISON COUNTY, INC. EMPLOYEE BENEFIT PLAN 2014 401k membership |
|---|
| Total participants, beginning-of-year | 2014-10-01 | 395 |
| Total number of active participants reported on line 7a of the Form 5500 | 2014-10-01 | 379 |
| Number of retired or separated participants receiving benefits | 2014-10-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2014-10-01 | 0 |
| Total of all active and inactive participants | 2014-10-01 | 379 |
| Number of employers contributing to the scheme | 2014-10-01 | 0 |
| 2013: COUNSELING SERVICE OF ADDISON COUNTY, INC. EMPLOYEE BENEFIT PLAN 2013 401k membership |
|---|
| Total participants, beginning-of-year | 2013-10-01 | 336 |
| Total number of active participants reported on line 7a of the Form 5500 | 2013-10-01 | 395 |
| Total of all active and inactive participants | 2013-10-01 | 395 |
| Number of retired or separated participants receiving benefits | 2013-10-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2013-10-01 | 0 |
| Number of employers contributing to the scheme | 2013-10-01 | 0 |
| 2012: COUNSELING SERVICE OF ADDISON COUNTY, INC. EMPLOYEE BENEFIT PLAN 2012 401k membership |
|---|
| Total participants, beginning-of-year | 2012-10-01 | 223 |
| Total number of active participants reported on line 7a of the Form 5500 | 2012-10-01 | 336 |
| Total of all active and inactive participants | 2012-10-01 | 336 |
| Number of retired or separated participants receiving benefits | 2012-10-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2012-10-01 | 0 |
| Number of employers contributing to the scheme | 2012-10-01 | 0 |
| 2011: COUNSELING SERVICE OF ADDISON COUNTY, INC. EMPLOYEE BENEFIT PLAN 2011 401k membership |
|---|
| Total participants, beginning-of-year | 2011-10-01 | 214 |
| Total number of active participants reported on line 7a of the Form 5500 | 2011-10-01 | 223 |
| Total of all active and inactive participants | 2011-10-01 | 223 |
| Number of retired or separated participants receiving benefits | 2011-10-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2011-10-01 | 0 |
| Number of employers contributing to the scheme | 2011-10-01 | 0 |
| 2010: COUNSELING SERVICE OF ADDISON COUNTY, INC. EMPLOYEE BENEFIT PLAN 2010 401k membership |
|---|
| Total participants, beginning-of-year | 2010-10-01 | 206 |
| Total number of active participants reported on line 7a of the Form 5500 | 2010-10-01 | 214 |
| Total of all active and inactive participants | 2010-10-01 | 214 |
| 2009: COUNSELING SERVICE OF ADDISON COUNTY, INC. EMPLOYEE BENEFIT PLAN 2009 401k membership |
|---|
| Total participants, beginning-of-year | 2009-10-01 | 157 |
| Total number of active participants reported on line 7a of the Form 5500 | 2009-10-01 | 206 |
| Total of all active and inactive participants | 2009-10-01 | 206 |
| AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 ) |
| Policy contract number | A8P08 |
| Policy instance | 3 |
| Insurance contract or identification number | A8P08 | | Number of Individuals Covered | 15 | | Insurance policy start date | 2021-11-01 | | Insurance policy end date | 2022-10-31 | | Total amount of commissions paid to insurance broker | USD $616 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENT, CRITICAL ILLNESS, HOSPITAL, CANCER | | Welfare Benefit Premiums Paid to Carrier | USD $9,678 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $141 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 226598 |
| Policy instance | 2 |
| Insurance contract or identification number | 226598 | | Number of Individuals Covered | 67 | | Insurance policy start date | 2021-11-01 | | Insurance policy end date | 2022-10-31 | | Total amount of commissions paid to insurance broker | USD $4,141 | | Total amount of fees paid to insurance company | USD $230 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $26,198 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,141 | | Amount paid for insurance broker fees | 230 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | | Insurance broker organization code? | 3 |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 30029018 |
| Policy instance | 1 |
| Insurance contract or identification number | 30029018 | | Number of Individuals Covered | 156 | | Insurance policy start date | 2021-11-01 | | Insurance policy end date | 2022-10-31 | | Total amount of commissions paid to insurance broker | USD $1,151 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $22,300 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,151 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | SGM604150 |
| Policy instance | 4 |
| Insurance contract or identification number | SGM604150 | | Number of Individuals Covered | 231 | | Insurance policy start date | 2021-05-01 | | Insurance policy end date | 2022-04-30 | | Total amount of commissions paid to insurance broker | USD $3,956 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $44,442 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $3,791 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 30029018 |
| Policy instance | 1 |
| Insurance contract or identification number | 30029018 | | Number of Individuals Covered | 160 | | Insurance policy start date | 2020-11-01 | | Insurance policy end date | 2021-10-31 | | Total amount of commissions paid to insurance broker | USD $1,246 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $22,779 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,246 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 226598 |
| Policy instance | 2 |
| Insurance contract or identification number | 226598 | | Number of Individuals Covered | 49 | | Insurance policy start date | 2020-11-01 | | Insurance policy end date | 2021-10-31 | | Total amount of commissions paid to insurance broker | USD $2,524 | | Total amount of fees paid to insurance company | USD $198 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $18,236 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,524 | | Amount paid for insurance broker fees | 198 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | | Insurance broker organization code? | 3 |
|
| AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 ) |
| Policy contract number | A8P08 |
| Policy instance | 3 |
| Insurance contract or identification number | A8P08 | | Number of Individuals Covered | 20 | | Insurance policy start date | 2020-11-01 | | Insurance policy end date | 2021-10-31 | | Total amount of commissions paid to insurance broker | USD $982 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENT, CRITICAL ILLNESS, HOSPITAL, CANCER | | Welfare Benefit Premiums Paid to Carrier | USD $15,612 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $316 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | SGM604150 |
| Policy instance | 4 |
| Insurance contract or identification number | SGM604150 | | Number of Individuals Covered | 216 | | Insurance policy start date | 2020-05-01 | | Insurance policy end date | 2021-04-30 | | Total amount of commissions paid to insurance broker | USD $6,153 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $62,440 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $4,959 | | Amount paid for insurance broker fees | 0 | | 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 | 614284 |
| Policy instance | 1 |
| Insurance contract or identification number | 614284 | | Number of Individuals Covered | 267 | | Insurance policy start date | 2019-11-01 | | Insurance policy end date | 2020-10-31 | | Total amount of commissions paid to insurance broker | USD $57,952 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $802,184 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $34,517 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 30029018 |
| Policy instance | 2 |
| Insurance contract or identification number | 30029018 | | Number of Individuals Covered | 161 | | Insurance policy start date | 2019-11-01 | | Insurance policy end date | 2020-10-31 | | Total amount of commissions paid to insurance broker | USD $1,118 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $24,235 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $904 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 226958 |
| Policy instance | 3 |
| Insurance contract or identification number | 226958 | | Number of Individuals Covered | 38 | | Insurance policy start date | 2019-11-01 | | Insurance policy end date | 2020-10-31 | | Total amount of commissions paid to insurance broker | USD $2,220 | | Total amount of fees paid to insurance company | USD $163 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $14,803 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,570 | | Amount paid for insurance broker fees | 131 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | | Insurance broker organization code? | 3 |
|
| AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 ) |
| Policy contract number | A8P08 |
| Policy instance | 4 |
| Insurance contract or identification number | A8P08 | | Number of Individuals Covered | 26 | | Insurance policy start date | 2019-11-01 | | Insurance policy end date | 2020-10-31 | | Total amount of commissions paid to insurance broker | USD $1,182 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENT, CRITICAL ILLNESS, HOSPITAL, CANCER | | Welfare Benefit Premiums Paid to Carrier | USD $16,099 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $367 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | SGM604150 |
| Policy instance | 5 |
| Insurance contract or identification number | SGM604150 | | Number of Individuals Covered | 171 | | Insurance policy start date | 2020-05-01 | | Insurance policy end date | 2020-10-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | 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 | 30029018 |
| Policy instance | 6 |
| Insurance contract or identification number | 30029018 | | Number of Individuals Covered | 161 | | Insurance policy start date | 2019-11-01 | | Insurance policy end date | 2020-10-31 | | Total amount of commissions paid to insurance broker | USD $1,118 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $24,235 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $904 | | Insurance broker organization code? | 3 |
|
| CBA BLUE (National Association of Insurance Commissioners NAIC id number: 0 ) |
| Policy contract number | 50660 |
| Policy instance | 1 |
| Insurance contract or identification number | 50660 | | Number of Individuals Covered | 183 | | Insurance policy start date | 2019-11-01 | | Insurance policy end date | 2020-10-31 | | Total amount of fees paid to insurance company | USD $12,327 | | Dental Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 12327 | | Additional information about fees paid to insurance broker | CONTRACT ADMINISTRATION | | Insurance broker organization code? | 5 |
|
| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
| Policy contract number | 00614284 |
| Policy instance | 2 |
| Insurance contract or identification number | 00614284 | | Number of Individuals Covered | 267 | | Insurance policy start date | 2019-11-01 | | Insurance policy end date | 2020-10-31 | | Total amount of commissions paid to insurance broker | USD $57,952 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $802,184 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $34,517 | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | SGD604141 |
| Policy instance | 3 |
| Insurance contract or identification number | SGD604141 | | Number of Individuals Covered | 261 | | Insurance policy start date | 2019-05-01 | | Insurance policy end date | 2020-05-01 | | Total amount of commissions paid to insurance broker | USD $4,111 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $42,215 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,111 | | Additional information about fees paid to insurance broker | SALES & SERVICE |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | SOK602721 |
| Policy instance | 4 |
| Insurance contract or identification number | SOK602721 | | Number of Individuals Covered | 261 | | Insurance policy start date | 2019-05-01 | | Insurance policy end date | 2020-05-01 | | Total amount of commissions paid to insurance broker | USD $277 | | Other welfare benefits provided | ACCIDENTAL DEATH | | Welfare Benefit Premiums Paid to Carrier | USD $2,309 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $277 | | Additional information about fees paid to insurance broker | SALE & SERVICE |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | SGM604150 |
| Policy instance | 5 |
| Insurance contract or identification number | SGM604150 | | Number of Individuals Covered | 261 | | Insurance policy start date | 2019-05-01 | | Insurance policy end date | 2020-05-01 | | Total amount of commissions paid to insurance broker | USD $2,021 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $21,723 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,021 | | Additional information about fees paid to insurance broker | SALES & SERVICE |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 00554344 |
| Policy instance | 7 |
| Insurance contract or identification number | 00554344 | | Number of Individuals Covered | 244 | | Insurance policy start date | 2019-11-01 | | Insurance policy end date | 2020-10-31 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $7,458 | | 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 | 00614284 |
| Policy instance | 2 |
| Insurance contract or identification number | 00614284 | | Number of Individuals Covered | 298 | | Insurance policy start date | 2018-11-01 | | Insurance policy end date | 2019-10-31 | | Total amount of commissions paid to insurance broker | USD $61,061 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $673,747 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $61,061 | | Insurance broker organization code? | 3 |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 30029018 |
| Policy instance | 2 |
| Insurance contract or identification number | 30029018 | | Number of Individuals Covered | 182 | | Insurance policy start date | 2017-11-01 | | Insurance policy end date | 2018-10-31 | | 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 $20,749 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | SGD604141 |
| Policy instance | 3 |
| Insurance contract or identification number | SGD604141 | | Number of Individuals Covered | 298 | | Insurance policy start date | 2018-05-01 | | Insurance policy end date | 2019-05-01 | | Total amount of commissions paid to insurance broker | USD $4,276 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $45,517 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,276 | | Additional information about fees paid to insurance broker | SALES & SERVICE |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | SOK602721 |
| Policy instance | 4 |
| Insurance contract or identification number | SOK602721 | | Number of Individuals Covered | 298 | | Insurance policy start date | 2018-05-01 | | Insurance policy end date | 2019-05-01 | | Total amount of commissions paid to insurance broker | USD $299 | | Other welfare benefits provided | ACCIDENTAL DEATH | | Welfare Benefit Premiums Paid to Carrier | USD $2,489 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $299 | | Additional information about fees paid to insurance broker | SALE & SERVICE |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | SGM604150 |
| Policy instance | 5 |
| Insurance contract or identification number | SGM604150 | | Number of Individuals Covered | 298 | | Insurance policy start date | 2018-05-01 | | Insurance policy end date | 2019-05-01 | | Total amount of commissions paid to insurance broker | USD $1,981 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $21,159 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,981 | | Additional information about fees paid to insurance broker | SALES & SERVICE | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 30029018 |
| Policy instance | 6 |
| Insurance contract or identification number | 30029018 | | Number of Individuals Covered | 166 | | Insurance policy start date | 2018-07-01 | | Insurance policy end date | 2019-06-30 | | Total amount of commissions paid to insurance broker | USD $1,141 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $21,228 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,141 | | Insurance broker organization code? | 3 |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 00554344 |
| Policy instance | 7 |
| Insurance contract or identification number | 00554344 | | Number of Individuals Covered | 260 | | Insurance policy start date | 2018-11-01 | | Insurance policy end date | 2019-10-31 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $7,055 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Insurance broker organization code? | 3 |
|
| AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 ) |
| Policy contract number | A8P08 |
| Policy instance | 3 |
| Insurance contract or identification number | A8P08 | | Number of Individuals Covered | 31 | | Insurance policy start date | 2017-11-01 | | Insurance policy end date | 2018-10-31 | | Total amount of commissions paid to insurance broker | USD $2,867 | | Total amount of fees paid to insurance company | USD $91 | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENT, CRITICAL ILLNESS, HOSPITAL, CANCER | | Welfare Benefit Premiums Paid to Carrier | USD $20,220 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $797 | | Amount paid for insurance broker fees | 15 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 226598 |
| Policy instance | 4 |
| Insurance contract or identification number | 226598 | | Number of Individuals Covered | 37 | | Insurance policy start date | 2017-11-01 | | Insurance policy end date | 2018-10-31 | | Total amount of commissions paid to insurance broker | USD $2,169 | | Total amount of fees paid to insurance company | USD $191 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $14,461 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,169 | | Amount paid for insurance broker fees | 191 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | | Insurance broker organization code? | 3 |
|
| CBA BLUE (National Association of Insurance Commissioners NAIC id number: 0 ) |
| Policy contract number | 50660 |
| Policy instance | 1 |
| Insurance contract or identification number | 50660 | | Number of Individuals Covered | 198 | | Insurance policy start date | 2018-11-01 | | Insurance policy end date | 2019-10-31 | | Total amount of fees paid to insurance company | USD $12,733 | | Dental Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 12733 | | Additional information about fees paid to insurance broker | CONTRACT ADMINISTRATION | | Insurance broker organization code? | 5 |
|
| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
| Policy contract number | 614284 |
| Policy instance | 1 |
| Insurance contract or identification number | 614284 | | Number of Individuals Covered | 299 | | Insurance policy start date | 2017-11-01 | | Insurance policy end date | 2018-10-31 | | Total amount of commissions paid to insurance broker | USD $63,088 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $682,026 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $63,088 | | Amount paid for insurance broker fees | 0 | | 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 | 614284 |
| Policy instance | 1 |
| Insurance contract or identification number | 614284 | | Number of Individuals Covered | 306 | | Insurance policy start date | 2016-11-01 | | Insurance policy end date | 2017-10-31 | | Total amount of commissions paid to insurance broker | USD $64,088 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $660,095 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $64,088 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 30029018 |
| Policy instance | 2 |
| Insurance contract or identification number | 30029018 | | Number of Individuals Covered | 174 | | Insurance policy start date | 2016-11-01 | | Insurance policy end date | 2017-10-31 | | 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 $20,388 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 ) |
| Policy contract number | A8P08 |
| Policy instance | 3 |
| Insurance contract or identification number | A8P08 | | Number of Individuals Covered | 30 | | Insurance policy start date | 2016-11-01 | | Insurance policy end date | 2017-10-31 | | Total amount of commissions paid to insurance broker | USD $3,021 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENT, CRITICAL ILLNESS, HOSPITAL, CANCER | | Welfare Benefit Premiums Paid to Carrier | USD $18,642 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,414 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 226598 |
| Policy instance | 4 |
| Insurance contract or identification number | 226598 | | Number of Individuals Covered | 41 | | Insurance policy start date | 2016-11-01 | | Insurance policy end date | 2017-10-31 | | Total amount of commissions paid to insurance broker | USD $2,001 | | Total amount of fees paid to insurance company | USD $233 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $13,339 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,001 | | Amount paid for insurance broker fees | 233 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | | Insurance broker organization code? | 3 |
|
| CBA BLUE (National Association of Insurance Commissioners NAIC id number: 0 ) |
| Policy contract number | 50660 |
| Policy instance | 1 |
| Insurance contract or identification number | 50660 | | Number of Individuals Covered | 203 | | Insurance policy start date | 2017-11-01 | | Insurance policy end date | 2018-10-31 | | Total amount of fees paid to insurance company | USD $19,874 | | Dental Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 19874 | | Additional information about fees paid to insurance broker | CONTRACT ADMINISTRATION | | Insurance broker organization code? | 5 | | Insurance broker name | CBA BLUE |
|
| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
| Policy contract number | 00614284 |
| Policy instance | 2 |
| Insurance contract or identification number | 00614284 | | Number of Individuals Covered | 299 | | Insurance policy start date | 2017-11-01 | | Insurance policy end date | 2018-10-31 | | Total amount of commissions paid to insurance broker | USD $63,088 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $682,026 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $63,088 | | Insurance broker organization code? | 3 | | Insurance broker name | HICKOCK & BOARDMAN |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 30029018 |
| Policy instance | 6 |
| Insurance contract or identification number | 30029018 | | Number of Individuals Covered | 170 | | Insurance policy start date | 2017-07-01 | | Insurance policy end date | 2018-06-30 | | Total amount of commissions paid to insurance broker | USD $1,148 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $21,293 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,148 | | Insurance broker organization code? | 3 | | Insurance broker name | HICKOK & BOARDMAN FINANCIAL |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | SGM604150 |
| Policy instance | 5 |
| Insurance contract or identification number | SGM604150 | | Number of Individuals Covered | 299 | | Insurance policy start date | 2017-05-01 | | Insurance policy end date | 2018-05-01 | | Total amount of commissions paid to insurance broker | USD $1,925 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $20,360 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,925 | | Additional information about fees paid to insurance broker | SALES & SERVICE | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | HICKOK & BOARDMAN |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | SOK602721 |
| Policy instance | 4 |
| Insurance contract or identification number | SOK602721 | | Number of Individuals Covered | 299 | | Insurance policy start date | 2017-05-01 | | Insurance policy end date | 2018-05-01 | | Total amount of commissions paid to insurance broker | USD $287 | | Other welfare benefits provided | ACCIDENTAL DEATH | | Welfare Benefit Premiums Paid to Carrier | USD $2,395 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $287 | | Additional information about fees paid to insurance broker | SALE & SERVICE | | Insurance broker name | HICKOK & BOARDMAN FINANCIAL |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | SGD604141 |
| Policy instance | 3 |
| Insurance contract or identification number | SGD604141 | | Number of Individuals Covered | 299 | | Insurance policy start date | 2017-05-01 | | Insurance policy end date | 2018-05-01 | | Total amount of commissions paid to insurance broker | USD $4,173 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $43,457 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,173 | | Additional information about fees paid to insurance broker | SALES & SERVICE | | Insurance broker name | HICKOK & BOARDMAN FINANCIAL |
|
| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
| Policy contract number | 614284 |
| Policy instance | 1 |
| Insurance contract or identification number | 614284 | | Number of Individuals Covered | 303 | | Insurance policy start date | 2015-11-01 | | Insurance policy end date | 2016-10-31 | | Total amount of commissions paid to insurance broker | USD $64,142 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $597,374 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $64,142 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 30029018 |
| Policy instance | 2 |
| Insurance contract or identification number | 30029018 | | Number of Individuals Covered | 155 | | Insurance policy start date | 2015-11-01 | | Insurance policy end date | 2016-10-31 | | 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 $18,073 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 ) |
| Policy contract number | A8P08 |
| Policy instance | 3 |
| Insurance contract or identification number | A8P08 | | Number of Individuals Covered | 33 | | Insurance policy start date | 2015-11-01 | | Insurance policy end date | 2016-10-31 | | Total amount of commissions paid to insurance broker | USD $1,455 | | Total amount of fees paid to insurance company | USD $39 | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENT, CRITICAL ILLNESS, HOSPITAL, CANCER | | Welfare Benefit Premiums Paid to Carrier | USD $19,852 | | 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 | 30 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 226598 |
| Policy instance | 4 |
| Insurance contract or identification number | 226598 | | Number of Individuals Covered | 41 | | Insurance policy start date | 2015-11-01 | | Insurance policy end date | 2016-10-31 | | Total amount of commissions paid to insurance broker | USD $1,744 | | Total amount of fees paid to insurance company | USD $203 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $11,625 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,744 | | Amount paid for insurance broker fees | 203 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | SGM604150 |
| Policy instance | 5 |
| Insurance contract or identification number | SGM604150 | | Number of Individuals Covered | 303 | | Insurance policy start date | 2016-05-01 | | Insurance policy end date | 2017-04-30 | | Total amount of commissions paid to insurance broker | USD $6,147 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $62,115 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,147 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 226598 |
| Policy instance | 4 |
| Insurance contract or identification number | 226598 | | Number of Individuals Covered | 303 | | Insurance policy start date | 2014-11-01 | | Insurance policy end date | 2015-10-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 30029018 |
| Policy instance | 2 |
| Insurance contract or identification number | 30029018 | | Number of Individuals Covered | 156 | | Insurance policy start date | 2014-11-01 | | Insurance policy end date | 2015-10-31 | | 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 $18,382 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 ) |
| Policy contract number | A8P08 |
| Policy instance | 3 |
| Insurance contract or identification number | A8P08 | | Number of Individuals Covered | 32 | | Insurance policy start date | 2014-11-01 | | Insurance policy end date | 2015-10-31 | | Total amount of commissions paid to insurance broker | USD $2,675 | | Total amount of fees paid to insurance company | USD $196 | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENT, CRITICAL ILLNESS, HOSPITAL, CANCER | | Welfare Benefit Premiums Paid to Carrier | USD $21,581 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,066 | | Amount paid for insurance broker fees | 110 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker organization code? | 3 |
|
| MVP HEALTH CARE (National Association of Insurance Commissioners NAIC id number: 95521 ) |
| Policy contract number | 213434 |
| Policy instance | 1 |
| Insurance contract or identification number | 213434 | | Number of Individuals Covered | 379 | | Insurance policy start date | 2014-11-01 | | Insurance policy end date | 2015-10-31 | | Total amount of commissions paid to insurance broker | USD $69,750 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $2,111,173 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $69,750 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | SGM604150 |
| Policy instance | 5 |
| Insurance contract or identification number | SGM604150 | | Number of Individuals Covered | 303 | | Insurance policy start date | 2015-05-01 | | Insurance policy end date | 2016-05-01 | | Total amount of commissions paid to insurance broker | USD $1,800 | | Total amount of fees paid to insurance company | USD $257 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $18,567 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,800 | | Amount paid for insurance broker fees | 257 | | Additional information about fees paid to insurance broker | SALES & SERVICE | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Insurance broker organization code? | 3 | | Insurance broker name | HICKOK & BOARDMAN |
|
| CBA BLUE (National Association of Insurance Commissioners NAIC id number: 0 ) |
| Policy contract number | 50660 |
| Policy instance | 1 |
| Insurance contract or identification number | 50660 | | Number of Individuals Covered | 201 | | Insurance policy start date | 2015-11-01 | | Insurance policy end date | 2016-10-31 | | Total amount of fees paid to insurance company | USD $17,549 | | Dental Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 17549 | | Additional information about fees paid to insurance broker | CONTRACT ADMINISTRATION | | Insurance broker organization code? | 5 | | Insurance broker name | CBA BLUE |
|
| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
| Policy contract number | 00614284 |
| Policy instance | 2 |
| Insurance contract or identification number | 00614284 | | Number of Individuals Covered | 303 | | Insurance policy start date | 2015-11-01 | | Insurance policy end date | 2016-10-31 | | Total amount of commissions paid to insurance broker | USD $64,142 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $597,374 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $64,142 | | Insurance broker organization code? | 3 | | Insurance broker name | HICKOCK & BOARDMAN |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | SOK602721 |
| Policy instance | 4 |
| Insurance contract or identification number | SOK602721 | | Number of Individuals Covered | 303 | | Insurance policy start date | 2015-05-01 | | Insurance policy end date | 2016-05-01 | | Total amount of commissions paid to insurance broker | USD $263 | | Total amount of fees paid to insurance company | USD $32 | | Other welfare benefits provided | ACCIDENTAL DEATH | | Welfare Benefit Premiums Paid to Carrier | USD $2,195 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $263 | | Amount paid for insurance broker fees | 32 | | Additional information about fees paid to insurance broker | SALE & SERVICE | | Insurance broker name | HICKOK & BOARDMAN FINANCIAL |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 30029018 |
| Policy instance | 6 |
| Insurance contract or identification number | 30029018 | | Number of Individuals Covered | 166 | | Insurance policy start date | 2015-05-01 | | Insurance policy end date | 2016-04-30 | | Total amount of commissions paid to insurance broker | USD $1,104 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $19,801 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,104 | | Insurance broker organization code? | 3 | | Insurance broker name | HICKOK & BOARDMAN FINANCIAL |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | SGD604141 |
| Policy instance | 3 |
| Insurance contract or identification number | SGD604141 | | Number of Individuals Covered | 303 | | Insurance policy start date | 2015-05-01 | | Insurance policy end date | 2016-05-01 | | Total amount of commissions paid to insurance broker | USD $3,969 | | Total amount of fees paid to insurance company | USD $539 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $39,372 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,969 | | Amount paid for insurance broker fees | 539 | | Additional information about fees paid to insurance broker | SALES & SERVICE | | Insurance broker name | HICKOK & BOARDMAN FINANCIAL |
|
| MVP HEALTH CARE (National Association of Insurance Commissioners NAIC id number: 95521 ) |
| Policy contract number | 213434 |
| Policy instance | 2 |
| Insurance contract or identification number | 213434 | | Number of Individuals Covered | 379 | | Insurance policy start date | 2014-11-01 | | Insurance policy end date | 2015-10-31 | | Total amount of commissions paid to insurance broker | USD $69,750 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $2,111,173 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $69,750 | | Insurance broker organization code? | 3 | | Insurance broker name | HICKOCK & BOARDMAN |
|
| MVP HEALTH CARE (National Association of Insurance Commissioners NAIC id number: 95521 ) |
| Policy contract number | 213434 |
| Policy instance | 1 |
| Insurance contract or identification number | 213434 | | Number of Individuals Covered | 395 | | Insurance policy start date | 2013-11-01 | | Insurance policy end date | 2014-10-31 | | Total amount of commissions paid to insurance broker | USD $68,580 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $2,122,438 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $68,580 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 30029018 |
| Policy instance | 2 |
| Insurance contract or identification number | 30029018 | | Number of Individuals Covered | 156 | | Insurance policy start date | 2013-11-01 | | Insurance policy end date | 2014-10-31 | | 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 $15,699 | | 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 | 226598 |
| Policy instance | 4 |
| Insurance contract or identification number | 226598 | | Number of Individuals Covered | 379 | | Insurance policy start date | 2013-11-01 | | Insurance policy end date | 2014-10-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 30029018 |
| Policy instance | 6 |
| Insurance contract or identification number | 30029018 | | Number of Individuals Covered | 160 | | Insurance policy start date | 2014-05-01 | | Insurance policy end date | 2015-04-30 | | Total amount of commissions paid to insurance broker | USD $1,078 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $18,872 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,078 | | Insurance broker organization code? | 3 | | Insurance broker name | HICKOK & BOARDMAN FINANCIAL |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | SGM604150 |
| Policy instance | 5 |
| Insurance contract or identification number | SGM604150 | | Number of Individuals Covered | 255 | | Insurance policy start date | 2014-05-01 | | Insurance policy end date | 2015-04-30 | | Total amount of commissions paid to insurance broker | USD $1,695 | | Total amount of fees paid to insurance company | USD $276 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $17,074 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,695 | | Amount paid for insurance broker fees | 276 | | Additional information about fees paid to insurance broker | SALES & SERVICE | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Insurance broker organization code? | 3 | | Insurance broker name | HICKOK & BOARDMAN |
|
| AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 ) |
| Policy contract number | A8P08 |
| Policy instance | 3 |
| Insurance contract or identification number | A8P08 | | Number of Individuals Covered | 38 | | Insurance policy start date | 2013-11-01 | | Insurance policy end date | 2014-10-31 | | Total amount of commissions paid to insurance broker | USD $2,757 | | Total amount of fees paid to insurance company | USD $171 | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENT, CRITICAL ILLNESS, HOSPITAL, CANCER | | Welfare Benefit Premiums Paid to Carrier | USD $21,256 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $836 | | Amount paid for insurance broker fees | 95 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker organization code? | 3 |
|
| CBA BLUE (National Association of Insurance Commissioners NAIC id number: 0 ) |
| Policy contract number | 50660 |
| Policy instance | 1 |
| Insurance contract or identification number | 50660 | | Number of Individuals Covered | 197 | | Insurance policy start date | 2014-11-01 | | Insurance policy end date | 2015-10-31 | | Total amount of fees paid to insurance company | USD $17,159 | | Dental Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 17159 | | Additional information about fees paid to insurance broker | CONTRACT ADMINISTRATION | | Insurance broker organization code? | 5 | | Insurance broker name | CBA BLUE |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | SGD604141 |
| Policy instance | 3 |
| Insurance contract or identification number | SGD604141 | | Number of Individuals Covered | 255 | | Insurance policy start date | 2014-05-01 | | Insurance policy end date | 2015-05-01 | | Total amount of commissions paid to insurance broker | USD $3,791 | | Total amount of fees paid to insurance company | USD $578 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $35,815 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,791 | | Amount paid for insurance broker fees | 578 | | Additional information about fees paid to insurance broker | SALES & SERVICE | | Insurance broker name | HICKOK & BOARDMAN FINANCIAL |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | SOK602721 |
| Policy instance | 4 |
| Insurance contract or identification number | SOK602721 | | Number of Individuals Covered | 255 | | Insurance policy start date | 2014-05-01 | | Insurance policy end date | 2015-04-30 | | Total amount of commissions paid to insurance broker | USD $256 | | Total amount of fees paid to insurance company | USD $34 | | Other welfare benefits provided | ACCIDENTAL DEATH | | Welfare Benefit Premiums Paid to Carrier | USD $2,134 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $256 | | Amount paid for insurance broker fees | 34 | | Additional information about fees paid to insurance broker | SALE & SERVICE | | Insurance broker name | HICKOK & BOARDMAN FINANCIAL |
|
| MVP HEALTH CARE (National Association of Insurance Commissioners NAIC id number: 95521 ) |
| Policy contract number | 213434 |
| Policy instance | 2 |
| Insurance contract or identification number | 213434 | | Number of Individuals Covered | 395 | | Insurance policy start date | 2013-11-01 | | Insurance policy end date | 2014-10-31 | | Total amount of commissions paid to insurance broker | USD $68,580 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $2,122,438 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $68,580 | | Insurance broker name | HICKOCK & BOARDMAN |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 30029018 |
| Policy instance | 7 |
| Insurance contract or identification number | 30029018 | | Number of Individuals Covered | 155 | | Insurance policy start date | 2013-05-01 | | Insurance policy end date | 2014-04-30 | | Total amount of commissions paid to insurance broker | USD $997 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $16,513 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $997 | | Insurance broker name | HICKOK & BOARDMAN FINANCIAL |
|
| CBA BLUE (National Association of Insurance Commissioners NAIC id number: 0 ) |
| Policy contract number | 50660 |
| Policy instance | 1 |
| Insurance contract or identification number | 50660 | | Number of Individuals Covered | 196 | | Insurance policy start date | 2013-11-01 | | Insurance policy end date | 2014-10-31 | | Total amount of fees paid to insurance company | USD $17,011 | | Dental Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 17011 | | Additional information about fees paid to insurance broker | CONTRACT ADMINISTRATION | | Insurance broker organization code? | 5 | | Insurance broker name | CBA BLUE |
|
| MVP HEALTH CARE (National Association of Insurance Commissioners NAIC id number: 95521 ) |
| Policy contract number | 213434 |
| Policy instance | 1 |
| Insurance contract or identification number | 213434 | | Number of Individuals Covered | 336 | | Insurance policy start date | 2012-11-01 | | Insurance policy end date | 2013-10-31 | | Total amount of commissions paid to insurance broker | USD $60,014 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,826,648 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $60,014 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | SGD604141 |
| Policy instance | 4 |
| Insurance contract or identification number | SGD604141 | | Number of Individuals Covered | 258 | | Insurance policy start date | 2013-05-01 | | Insurance policy end date | 2014-05-01 | | Total amount of commissions paid to insurance broker | USD $3,549 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $31,088 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,549 | | Additional information about fees paid to insurance broker | SALES & SERVICE | | Insurance broker name | HICKOK & BOARDMAN FINANCIAL |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | SOK602721 |
| Policy instance | 5 |
| Insurance contract or identification number | SOK602721 | | Number of Individuals Covered | 258 | | Insurance policy start date | 2013-05-01 | | Insurance policy end date | 2014-05-01 | | Total amount of commissions paid to insurance broker | USD $227 | | Other welfare benefits provided | ACCIDENTAL DEATH | | Welfare Benefit Premiums Paid to Carrier | USD $1,852 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $227 | | Additional information about fees paid to insurance broker | SALE & SERVICE | | Insurance broker name | HICKOK & BOARDMAN FINANCIAL |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 226598 |
| Policy instance | 3 |
| Insurance contract or identification number | 226598 | | Number of Individuals Covered | 46 | | Insurance policy start date | 2013-05-01 | | Insurance policy end date | 2014-05-01 | | Total amount of commissions paid to insurance broker | USD $1,806 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $10,784 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,806 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Insurance broker name | HICKOCK & BOARDMAN |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | SGM604150 |
| Policy instance | 6 |
| Insurance contract or identification number | SGM604150 | | Number of Individuals Covered | 258 | | Insurance policy start date | 2013-05-01 | | Insurance policy end date | 2014-05-01 | | Total amount of commissions paid to insurance broker | USD $1,537 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $14,813 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,537 | | Additional information about fees paid to insurance broker | SALES & SERVICE | | Insurance broker name | HICKOK & BOARDMAN |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | SGM604150 |
| Policy instance | 5 |
| Insurance contract or identification number | SGM604150 | | Number of Individuals Covered | 258 | | Insurance policy start date | 2013-05-01 | | Insurance policy end date | 2014-04-30 | | Total amount of commissions paid to insurance broker | USD $5,313 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $47,753 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,313 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 ) |
| Policy contract number | A8P08 |
| Policy instance | 4 |
| Insurance contract or identification number | A8P08 | | Number of Individuals Covered | 395 | | Insurance policy start date | 2012-11-01 | | Insurance policy end date | 2013-10-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENT, CRITICAL ILLNESS, HOSPITAL, CANCER | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 30029018 |
| Policy instance | 2 |
| Insurance contract or identification number | 30029018 | | Number of Individuals Covered | 137 | | Insurance policy start date | 2012-11-01 | | Insurance policy end date | 2013-10-31 | | 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 $14,085 | | 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 | 131778 |
| Policy instance | 3 |
| Insurance contract or identification number | 131778 | | Number of Individuals Covered | 239 | | Insurance policy start date | 2012-04-01 | | Insurance policy end date | 2013-03-31 | | Total amount of commissions paid to insurance broker | USD $6,262 | | 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 | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $51,319 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,364 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| MVP HEALTH CARE (National Association of Insurance Commissioners NAIC id number: 95521 ) |
| Policy contract number | 213434 |
| Policy instance | 1 |
| Insurance contract or identification number | 213434 | | Number of Individuals Covered | 335 | | Insurance policy start date | 2011-11-01 | | Insurance policy end date | 2012-10-31 | | Total amount of commissions paid to insurance broker | USD $51,110 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,550,395 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $51,110 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 ) |
| Policy contract number | A8P08 |
| Policy instance | 6 |
| Insurance contract or identification number | A8P08 | | Number of Individuals Covered | 336 | | Insurance policy start date | 2011-11-01 | | Insurance policy end date | 2012-10-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENT, CRITICAL ILLNESS, HOSPITAL, CANCER | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 131778 |
| Policy instance | 4 |
| Insurance contract or identification number | 131778 | | Number of Individuals Covered | 239 | | Insurance policy start date | 2012-04-01 | | Insurance policy end date | 2013-04-01 | | Total amount of commissions paid to insurance broker | USD $6,262 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $51,319 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,364 | | Insurance broker name | HICKOCK & BOARDMAN |
|
| MVP HEALTH CARE (National Association of Insurance Commissioners NAIC id number: 95521 ) |
| Policy contract number | 213434 |
| Policy instance | 3 |
| Insurance contract or identification number | 213434 | | Number of Individuals Covered | 336 | | Insurance policy start date | 2012-11-01 | | Insurance policy end date | 2013-10-31 | | Total amount of commissions paid to insurance broker | USD $60,014 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,826,648 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $60,014 | | Insurance broker name | HICKOCK & BOARDMAN |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 30029018 |
| Policy instance | 2 |
| Insurance contract or identification number | 30029018 | | Number of Individuals Covered | 140 | | Insurance policy start date | 2012-07-01 | | Insurance policy end date | 2013-06-30 | | Total amount of commissions paid to insurance broker | USD $951 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $15,164 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $951 | | Total amount of fees paid to insurance company | USD $0 | | Insurance broker name | HICKOCK & BOARDMAN |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 226598 |
| Policy instance | 4 |
| Insurance contract or identification number | 226598 | | Number of Individuals Covered | 336 | | Insurance policy start date | 2012-03-01 | | Insurance policy end date | 2012-10-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 131778 |
| Policy instance | 5 |
| Insurance contract or identification number | 131778 | | Number of Individuals Covered | 336 | | Insurance policy start date | 2013-04-01 | | Insurance policy end date | 2013-04-30 | | Total amount of commissions paid to insurance broker | USD $0 | | 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 | ACCIDENTAL DEATH AND DISMEMBERMENT | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 226598 |
| Policy instance | 5 |
| Insurance contract or identification number | 226598 | | Number of Individuals Covered | 46 | | Insurance policy start date | 2012-04-01 | | Insurance policy end date | 2013-04-01 | | Total amount of commissions paid to insurance broker | USD $2,151 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $9,213 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,151 | | Insurance broker name | HICKOCK & BOARDMAN |
|
| CBA BLUE (National Association of Insurance Commissioners NAIC id number: 0 ) |
| Policy contract number | 50660 |
| Policy instance | 1 |
| Insurance contract or identification number | 50660 | | Number of Individuals Covered | 183 | | Insurance policy start date | 2012-11-01 | | Insurance policy end date | 2013-10-31 | | Total amount of fees paid to insurance company | USD $15,332 | | Dental Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 15332 | | Additional information about fees paid to insurance broker | CONTRACT ADMINISTRATION | | Insurance broker organization code? | 5 | | Insurance broker name | CBA BLUE |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 131778 |
| Policy instance | 4 |
| Insurance contract or identification number | 131778 | | Number of Individuals Covered | 225 | | Insurance policy start date | 2011-04-01 | | Insurance policy end date | 2012-04-01 | | Total amount of commissions paid to insurance broker | USD $5,663 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $47,201 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MVP HEALTH CARE (National Association of Insurance Commissioners NAIC id number: 95521 ) |
| Policy contract number | 213434 |
| Policy instance | 1 |
| Insurance contract or identification number | 213434 | | Number of Individuals Covered | 316 | | Insurance policy start date | 2010-11-01 | | Insurance policy end date | 2011-10-31 | | Total amount of commissions paid to insurance broker | USD $50,039 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,550,641 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $25,504 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 30029018 |
| Policy instance | 2 |
| Insurance contract or identification number | 30029018 | | Number of Individuals Covered | 122 | | Insurance policy start date | 2011-07-01 | | Insurance policy end date | 2012-06-30 | | Total amount of commissions paid to insurance broker | USD $690 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $8,795 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Total amount of fees paid to insurance company | USD $0 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 131778 |
| Policy instance | 3 |
| Insurance contract or identification number | 131778 | | Number of Individuals Covered | 225 | | Insurance policy start date | 2011-04-01 | | Insurance policy end date | 2012-03-31 | | Total amount of commissions paid to insurance broker | USD $5,663 | | 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 | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $47,201 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,130 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| CBA BLUE (National Association of Insurance Commissioners NAIC id number: 0 ) |
| Policy contract number | 50660 |
| Policy instance | 1 |
| Insurance contract or identification number | 50660 | | Number of Individuals Covered | 223 | | Insurance policy start date | 2011-10-01 | | Insurance policy end date | 2012-09-30 | | Total amount of fees paid to insurance company | USD $14,471 | | Dental Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MVP HEALTH CARE (National Association of Insurance Commissioners NAIC id number: 95521 ) |
| Policy contract number | 213434 |
| Policy instance | 3 |
| Insurance contract or identification number | 213434 | | Number of Individuals Covered | 316 | | Insurance policy start date | 2010-11-01 | | Insurance policy end date | 2011-10-31 | | Total amount of commissions paid to insurance broker | USD $50,039 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,550,641 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 ) |
| Policy contract number | A8P08 |
| Policy instance | 4 |
| Insurance contract or identification number | A8P08 | | Number of Individuals Covered | 223 | | Insurance policy start date | 2010-11-01 | | Insurance policy end date | 2011-10-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENT, CRITICAL ILLNESS, HOSPITAL, CANCER | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| CBA BLUE (National Association of Insurance Commissioners NAIC id number: 0 ) |
| Policy contract number | 50660 |
| Policy instance | 1 |
| Insurance contract or identification number | 50660 | | Number of Individuals Covered | 214 | | Insurance policy start date | 2010-10-01 | | Insurance policy end date | 2011-09-30 | | Total amount of fees paid to insurance company | USD $12,831 | | Dental Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
