GOVERNOR DUMMER ACADEMY has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan THE GOVERNORS ACADEMY FLEXIBLE BENEFITS PLAN
| Measure | Date | Value |
|---|
| 2022: THE GOVERNORS ACADEMY FLEXIBLE BENEFITS PLAN 2022 401k membership |
|---|
| Total participants, beginning-of-year | 2022-06-01 | 157 |
| Total number of active participants reported on line 7a of the Form 5500 | 2022-06-01 | 159 |
| Number of retired or separated participants receiving benefits | 2022-06-01 | 3 |
| Number of other retired or separated participants entitled to future benefits | 2022-06-01 | 0 |
| Total of all active and inactive participants | 2022-06-01 | 162 |
| Number of employers contributing to the scheme | 2022-06-01 | 0 |
| 2021: THE GOVERNORS ACADEMY FLEXIBLE BENEFITS PLAN 2021 401k membership |
|---|
| Total participants, beginning-of-year | 2021-06-01 | 158 |
| Total number of active participants reported on line 7a of the Form 5500 | 2021-06-01 | 156 |
| Number of retired or separated participants receiving benefits | 2021-06-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2021-06-01 | 0 |
| Total of all active and inactive participants | 2021-06-01 | 156 |
| Number of employers contributing to the scheme | 2021-06-01 | 0 |
| 2020: THE GOVERNORS ACADEMY FLEXIBLE BENEFITS PLAN 2020 401k membership |
|---|
| Total participants, beginning-of-year | 2020-06-01 | 158 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-06-01 | 158 |
| Number of retired or separated participants receiving benefits | 2020-06-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2020-06-01 | 0 |
| Total of all active and inactive participants | 2020-06-01 | 158 |
| Number of employers contributing to the scheme | 2020-06-01 | 0 |
| 2019: THE GOVERNORS ACADEMY FLEXIBLE BENEFITS PLAN 2019 401k membership |
|---|
| Total participants, beginning-of-year | 2019-06-01 | 158 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-06-01 | 158 |
| Number of retired or separated participants receiving benefits | 2019-06-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2019-06-01 | 0 |
| Total of all active and inactive participants | 2019-06-01 | 158 |
| Number of employers contributing to the scheme | 2019-06-01 | 0 |
| 2018: THE GOVERNORS ACADEMY FLEXIBLE BENEFITS PLAN 2018 401k membership |
|---|
| Total participants, beginning-of-year | 2018-06-01 | 158 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-06-01 | 158 |
| Number of retired or separated participants receiving benefits | 2018-06-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2018-06-01 | 0 |
| Total of all active and inactive participants | 2018-06-01 | 158 |
| Number of employers contributing to the scheme | 2018-06-01 | 0 |
| 2017: THE GOVERNORS ACADEMY FLEXIBLE BENEFITS PLAN 2017 401k membership |
|---|
| Total participants, beginning-of-year | 2017-06-01 | 159 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-06-01 | 159 |
| Number of retired or separated participants receiving benefits | 2017-06-01 | 1 |
| Number of other retired or separated participants entitled to future benefits | 2017-06-01 | 0 |
| Total of all active and inactive participants | 2017-06-01 | 160 |
| 2016: THE GOVERNORS ACADEMY FLEXIBLE BENEFITS PLAN 2016 401k membership |
|---|
| Total participants, beginning-of-year | 2016-06-01 | 154 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-06-01 | 157 |
| Number of retired or separated participants receiving benefits | 2016-06-01 | 1 |
| Number of other retired or separated participants entitled to future benefits | 2016-06-01 | 1 |
| Total of all active and inactive participants | 2016-06-01 | 159 |
| 2015: THE GOVERNORS ACADEMY FLEXIBLE BENEFITS PLAN 2015 401k membership |
|---|
| Total participants, beginning-of-year | 2015-06-01 | 155 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-06-01 | 152 |
| Number of retired or separated participants receiving benefits | 2015-06-01 | 2 |
| Number of other retired or separated participants entitled to future benefits | 2015-06-01 | 0 |
| Total of all active and inactive participants | 2015-06-01 | 154 |
| 2014: THE GOVERNORS ACADEMY FLEXIBLE BENEFITS PLAN 2014 401k membership |
|---|
| Total participants, beginning-of-year | 2014-06-01 | 115 |
| Total number of active participants reported on line 7a of the Form 5500 | 2014-06-01 | 118 |
| Number of retired or separated participants receiving benefits | 2014-06-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2014-06-01 | 0 |
| Total of all active and inactive participants | 2014-06-01 | 118 |
| 2013: THE GOVERNORS ACADEMY FLEXIBLE BENEFITS PLAN 2013 401k membership |
|---|
| Total participants, beginning-of-year | 2013-06-01 | 114 |
| Total number of active participants reported on line 7a of the Form 5500 | 2013-06-01 | 115 |
| Number of retired or separated participants receiving benefits | 2013-06-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2013-06-01 | 0 |
| Total of all active and inactive participants | 2013-06-01 | 115 |
| 2012: THE GOVERNORS ACADEMY FLEXIBLE BENEFITS PLAN 2012 401k membership |
|---|
| Total participants, beginning-of-year | 2012-06-01 | 109 |
| Total number of active participants reported on line 7a of the Form 5500 | 2012-06-01 | 117 |
| Number of retired or separated participants receiving benefits | 2012-06-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2012-06-01 | 0 |
| Total of all active and inactive participants | 2012-06-01 | 117 |
| 2011: THE GOVERNORS ACADEMY FLEXIBLE BENEFITS PLAN 2011 401k membership |
|---|
| Total participants, beginning-of-year | 2011-06-01 | 102 |
| Total number of active participants reported on line 7a of the Form 5500 | 2011-06-01 | 106 |
| Number of retired or separated participants receiving benefits | 2011-06-01 | 1 |
| Number of other retired or separated participants entitled to future benefits | 2011-06-01 | 0 |
| Total of all active and inactive participants | 2011-06-01 | 107 |
| 2010: THE GOVERNORS ACADEMY FLEXIBLE BENEFITS PLAN 2010 401k membership |
|---|
| Total participants, beginning-of-year | 2010-06-01 | 112 |
| Total number of active participants reported on line 7a of the Form 5500 | 2010-06-01 | 101 |
| Number of retired or separated participants receiving benefits | 2010-06-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2010-06-01 | 0 |
| Total of all active and inactive participants | 2010-06-01 | 101 |
| 2009: THE GOVERNORS ACADEMY FLEXIBLE BENEFITS PLAN 2009 401k membership |
|---|
| Total participants, beginning-of-year | 2009-06-01 | 108 |
| Total number of active participants reported on line 7a of the Form 5500 | 2009-06-01 | 101 |
| Number of retired or separated participants receiving benefits | 2009-06-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2009-06-01 | 0 |
| Total of all active and inactive participants | 2009-06-01 | 101 |
| Total participants | 2009-06-01 | 0 |
| 2008: THE GOVERNORS ACADEMY FLEXIBLE BENEFITS PLAN 2008 401k membership |
|---|
| Total participants, beginning-of-year | 2008-06-01 | 105 |
| Total number of active participants reported on line 7a of the Form 5500 | 2008-06-01 | 106 |
| Number of retired or separated participants receiving benefits | 2008-06-01 | 1 |
| Number of other retired or separated participants entitled to future benefits | 2008-06-01 | 0 |
| Total of all active and inactive participants | 2008-06-01 | 107 |
| 2007: THE GOVERNORS ACADEMY FLEXIBLE BENEFITS PLAN 2007 401k membership |
|---|
| Total participants, beginning-of-year | 2007-06-01 | 106 |
| Total number of active participants reported on line 7a of the Form 5500 | 2007-06-01 | 103 |
| Number of retired or separated participants receiving benefits | 2007-06-01 | 1 |
| Number of other retired or separated participants entitled to future benefits | 2007-06-01 | 0 |
| Total of all active and inactive participants | 2007-06-01 | 104 |
| 2006: THE GOVERNORS ACADEMY FLEXIBLE BENEFITS PLAN 2006 401k membership |
|---|
| Total participants, beginning-of-year | 2006-06-01 | 105 |
| Total number of active participants reported on line 7a of the Form 5500 | 2006-06-01 | 104 |
| Number of retired or separated participants receiving benefits | 2006-06-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2006-06-01 | 0 |
| Total of all active and inactive participants | 2006-06-01 | 104 |
| 2005: THE GOVERNORS ACADEMY FLEXIBLE BENEFITS PLAN 2005 401k membership |
|---|
| Total participants, beginning-of-year | 2005-06-01 | 107 |
| Total number of active participants reported on line 7a of the Form 5500 | 2005-06-01 | 100 |
| Number of retired or separated participants receiving benefits | 2005-06-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2005-06-01 | 0 |
| Total of all active and inactive participants | 2005-06-01 | 100 |
| 2004: THE GOVERNORS ACADEMY FLEXIBLE BENEFITS PLAN 2004 401k membership |
|---|
| Total participants, beginning-of-year | 2004-07-01 | 105 |
| Total number of active participants reported on line 7a of the Form 5500 | 2004-07-01 | 105 |
| Number of retired or separated participants receiving benefits | 2004-07-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2004-07-01 | 0 |
| Total of all active and inactive participants | 2004-07-01 | 105 |
| 2022: THE GOVERNORS ACADEMY FLEXIBLE BENEFITS PLAN 2022 form 5500 responses |
|---|
| 2022-06-01 | Type of plan entity | Single employer plan |
| 2022-06-01 | Plan funding arrangement – Insurance | Yes |
| 2022-06-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2022-06-01 | Plan benefit arrangement – Insurance | Yes |
| 2022-06-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2021: THE GOVERNORS ACADEMY FLEXIBLE BENEFITS PLAN 2021 form 5500 responses |
|---|
| 2021-06-01 | Type of plan entity | Single employer plan |
| 2021-06-01 | Plan funding arrangement – Insurance | Yes |
| 2021-06-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2021-06-01 | Plan benefit arrangement – Insurance | Yes |
| 2021-06-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2020: THE GOVERNORS ACADEMY FLEXIBLE BENEFITS PLAN 2020 form 5500 responses |
|---|
| 2020-06-01 | Type of plan entity | Single employer plan |
| 2020-06-01 | Plan funding arrangement – Insurance | Yes |
| 2020-06-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2020-06-01 | Plan benefit arrangement – Insurance | Yes |
| 2020-06-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2019: THE GOVERNORS ACADEMY FLEXIBLE BENEFITS PLAN 2019 form 5500 responses |
|---|
| 2019-06-01 | Type of plan entity | Single employer plan |
| 2019-06-01 | Plan funding arrangement – Insurance | Yes |
| 2019-06-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2019-06-01 | Plan benefit arrangement – Insurance | Yes |
| 2019-06-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2018: THE GOVERNORS ACADEMY FLEXIBLE BENEFITS PLAN 2018 form 5500 responses |
|---|
| 2018-06-01 | Type of plan entity | Single employer plan |
| 2018-06-01 | Plan funding arrangement – Insurance | Yes |
| 2018-06-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2018-06-01 | Plan benefit arrangement – Insurance | Yes |
| 2018-06-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2017: THE GOVERNORS ACADEMY FLEXIBLE BENEFITS PLAN 2017 form 5500 responses |
|---|
| 2017-06-01 | Type of plan entity | Single employer plan |
| 2017-06-01 | Plan funding arrangement – Insurance | Yes |
| 2017-06-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2017-06-01 | Plan benefit arrangement – Insurance | Yes |
| 2017-06-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2016: THE GOVERNORS ACADEMY FLEXIBLE BENEFITS PLAN 2016 form 5500 responses |
|---|
| 2016-06-01 | Type of plan entity | Single employer plan |
| 2016-06-01 | Submission has been amended | No |
| 2016-06-01 | This submission is the final filing | No |
| 2016-06-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2016-06-01 | Plan is a collectively bargained plan | No |
| 2016-06-01 | Plan funding arrangement – Insurance | Yes |
| 2016-06-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2016-06-01 | Plan benefit arrangement – Insurance | Yes |
| 2016-06-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2015: THE GOVERNORS ACADEMY FLEXIBLE BENEFITS PLAN 2015 form 5500 responses |
|---|
| 2015-06-01 | Type of plan entity | Single employer plan |
| 2015-06-01 | Submission has been amended | No |
| 2015-06-01 | This submission is the final filing | No |
| 2015-06-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2015-06-01 | Plan is a collectively bargained plan | No |
| 2015-06-01 | Plan funding arrangement – Insurance | Yes |
| 2015-06-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2015-06-01 | Plan benefit arrangement – Insurance | Yes |
| 2015-06-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2014: THE GOVERNORS ACADEMY FLEXIBLE BENEFITS PLAN 2014 form 5500 responses |
|---|
| 2014-06-01 | Type of plan entity | Single employer plan |
| 2014-06-01 | Submission has been amended | No |
| 2014-06-01 | This submission is the final filing | No |
| 2014-06-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2014-06-01 | Plan is a collectively bargained plan | No |
| 2014-06-01 | Plan funding arrangement – Insurance | Yes |
| 2014-06-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2014-06-01 | Plan benefit arrangement – Insurance | Yes |
| 2014-06-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2013: THE GOVERNORS ACADEMY FLEXIBLE BENEFITS PLAN 2013 form 5500 responses |
|---|
| 2013-06-01 | Type of plan entity | Single employer plan |
| 2013-06-01 | Submission has been amended | No |
| 2013-06-01 | This submission is the final filing | No |
| 2013-06-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2013-06-01 | Plan is a collectively bargained plan | No |
| 2013-06-01 | Plan funding arrangement – Insurance | Yes |
| 2013-06-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2013-06-01 | Plan benefit arrangement – Insurance | Yes |
| 2013-06-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2012: THE GOVERNORS ACADEMY FLEXIBLE BENEFITS PLAN 2012 form 5500 responses |
|---|
| 2012-06-01 | Type of plan entity | Single employer plan |
| 2012-06-01 | Submission has been amended | No |
| 2012-06-01 | This submission is the final filing | No |
| 2012-06-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2012-06-01 | Plan is a collectively bargained plan | No |
| 2012-06-01 | Plan funding arrangement – Insurance | Yes |
| 2012-06-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2012-06-01 | Plan benefit arrangement – Insurance | Yes |
| 2012-06-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2011: THE GOVERNORS ACADEMY FLEXIBLE BENEFITS PLAN 2011 form 5500 responses |
|---|
| 2011-06-01 | Type of plan entity | Single employer plan |
| 2011-06-01 | Submission has been amended | No |
| 2011-06-01 | This submission is the final filing | No |
| 2011-06-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2011-06-01 | Plan is a collectively bargained plan | No |
| 2011-06-01 | Plan funding arrangement – Insurance | Yes |
| 2011-06-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2011-06-01 | Plan benefit arrangement – Insurance | Yes |
| 2011-06-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2010: THE GOVERNORS ACADEMY FLEXIBLE BENEFITS PLAN 2010 form 5500 responses |
|---|
| 2010-06-01 | Type of plan entity | Single employer plan |
| 2010-06-01 | Submission has been amended | No |
| 2010-06-01 | This submission is the final filing | No |
| 2010-06-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2010-06-01 | Plan is a collectively bargained plan | No |
| 2010-06-01 | Plan funding arrangement – Insurance | Yes |
| 2010-06-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2010-06-01 | Plan benefit arrangement – Insurance | Yes |
| 2010-06-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2009: THE GOVERNORS ACADEMY FLEXIBLE BENEFITS PLAN 2009 form 5500 responses |
|---|
| 2009-06-01 | Type of plan entity | Single employer plan |
| 2009-06-01 | Submission has been amended | No |
| 2009-06-01 | This submission is the final filing | No |
| 2009-06-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2009-06-01 | Plan is a collectively bargained plan | No |
| 2009-06-01 | Plan funding arrangement – Insurance | Yes |
| 2009-06-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2009-06-01 | Plan benefit arrangement – Insurance | Yes |
| 2009-06-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2008: THE GOVERNORS ACADEMY FLEXIBLE BENEFITS PLAN 2008 form 5500 responses |
|---|
| 2008-06-01 | Type of plan entity | Single employer plan |
| 2008-06-01 | Submission has been amended | No |
| 2008-06-01 | This submission is the final filing | No |
| 2008-06-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2008-06-01 | Plan is a collectively bargained plan | No |
| 2008-06-01 | Plan funding arrangement – Insurance | Yes |
| 2008-06-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2008-06-01 | Plan benefit arrangement – Insurance | Yes |
| 2008-06-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2007: THE GOVERNORS ACADEMY FLEXIBLE BENEFITS PLAN 2007 form 5500 responses |
|---|
| 2007-06-01 | Type of plan entity | Single employer plan |
| 2007-06-01 | Submission has been amended | No |
| 2007-06-01 | This submission is the final filing | No |
| 2007-06-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2007-06-01 | Plan is a collectively bargained plan | No |
| 2007-06-01 | Plan funding arrangement – Insurance | Yes |
| 2007-06-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2007-06-01 | Plan benefit arrangement – Insurance | Yes |
| 2007-06-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2006: THE GOVERNORS ACADEMY FLEXIBLE BENEFITS PLAN 2006 form 5500 responses |
|---|
| 2006-06-01 | Type of plan entity | Single employer plan |
| 2006-06-01 | Submission has been amended | No |
| 2006-06-01 | This submission is the final filing | No |
| 2006-06-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2006-06-01 | Plan is a collectively bargained plan | No |
| 2006-06-01 | Plan funding arrangement – Insurance | Yes |
| 2006-06-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2006-06-01 | Plan benefit arrangement – Insurance | Yes |
| 2006-06-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2005: THE GOVERNORS ACADEMY FLEXIBLE BENEFITS PLAN 2005 form 5500 responses |
|---|
| 2005-06-01 | Type of plan entity | Single employer plan |
| 2005-06-01 | Submission has been amended | No |
| 2005-06-01 | This submission is the final filing | No |
| 2005-06-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2005-06-01 | Plan is a collectively bargained plan | No |
| 2005-06-01 | Plan funding arrangement – Insurance | Yes |
| 2005-06-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2005-06-01 | Plan benefit arrangement – Insurance | Yes |
| 2005-06-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2004: THE GOVERNORS ACADEMY FLEXIBLE BENEFITS PLAN 2004 form 5500 responses |
|---|
| 2004-07-01 | Type of plan entity | Single employer plan |
| 2004-07-01 | First time form 5500 has been submitted | Yes |
| 2004-07-01 | Submission has been amended | No |
| 2004-07-01 | This submission is the final filing | No |
| 2004-07-01 | This return/report is a short plan year return/report (less than 12 months) | Yes |
| 2004-07-01 | Plan is a collectively bargained plan | No |
| 2004-07-01 | Plan funding arrangement – Insurance | Yes |
| 2004-07-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2004-07-01 | Plan benefit arrangement – Insurance | Yes |
| 2004-07-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG0ACTD |
| Policy instance | 3 |
| Insurance contract or identification number | GLUG0ACTD | | Number of Individuals Covered | 160 | | Insurance policy start date | 2022-05-01 | | Insurance policy end date | 2023-04-30 | | Total amount of commissions paid to insurance broker | USD $8,043 | | Total amount of fees paid to insurance company | USD $6,059 | | 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 $102,758 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,043 | | Amount paid for insurance broker fees | 6059 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL OF MASSACHUSETTS (National Association of Insurance Commissioners NAIC id number: 52060 ) |
| Policy contract number | 19640036 |
| Policy instance | 2 |
| Insurance contract or identification number | 19640036 | | Number of Individuals Covered | 284 | | Insurance policy start date | 2021-07-01 | | Insurance policy end date | 2022-06-30 | | 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 | | Welfare Benefit Premiums Paid to Carrier | USD $155,244 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| BLUE CROSS BLUE SHIELD OF MASSACHUSETTS, INC. (National Association of Insurance Commissioners NAIC id number: 53228 ) |
| Policy contract number | 376863 |
| Policy instance | 1 |
| Insurance contract or identification number | 376863 | | Number of Individuals Covered | 215 | | Insurance policy start date | 2022-06-01 | | Insurance policy end date | 2023-05-31 | | Total amount of commissions paid to insurance broker | USD $1,533 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $1,533 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG0ACTD |
| Policy instance | 3 |
| Insurance contract or identification number | GLUG0ACTD | | Number of Individuals Covered | 157 | | Insurance policy start date | 2021-05-01 | | Insurance policy end date | 2022-04-30 | | Total amount of commissions paid to insurance broker | USD $7,909 | | Total amount of fees paid to insurance company | USD $4,434 | | 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 $98,781 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,909 | | Amount paid for insurance broker fees | 4434 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL OF MASSACHUSETTS (National Association of Insurance Commissioners NAIC id number: 52060 ) |
| Policy contract number | 19640036 |
| Policy instance | 2 |
| Insurance contract or identification number | 19640036 | | Number of Individuals Covered | 302 | | Insurance policy start date | 2020-07-01 | | Insurance policy end date | 2021-06-30 | | Total amount of commissions paid to insurance broker | USD $2,366 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $157,898 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,366 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| BLUE CROSS BLUE SHIELD OF MASSACHUSETTS, INC. (National Association of Insurance Commissioners NAIC id number: 53228 ) |
| Policy contract number | 376863 |
| Policy instance | 1 |
| Insurance contract or identification number | 376863 | | Number of Individuals Covered | 193 | | Insurance policy start date | 2021-06-01 | | Insurance policy end date | 2022-05-31 | | Total amount of commissions paid to insurance broker | USD $1,440 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $1,440 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG0ACTD |
| Policy instance | 3 |
| Insurance contract or identification number | GLUG0ACTD | | Number of Individuals Covered | 159 | | Insurance policy start date | 2020-05-01 | | Insurance policy end date | 2021-04-30 | | Total amount of commissions paid to insurance broker | USD $7,979 | | Total amount of fees paid to insurance company | USD $6,022 | | 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 $99,788 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,979 | | Amount paid for insurance broker fees | 6022 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL OF MASSACHUSETTS (National Association of Insurance Commissioners NAIC id number: 52060 ) |
| Policy contract number | 19640036 |
| Policy instance | 2 |
| Insurance contract or identification number | 19640036 | | Number of Individuals Covered | 300 | | Insurance policy start date | 2019-07-01 | | Insurance policy end date | 2020-06-30 | | Total amount of commissions paid to insurance broker | USD $2,418 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $161,408 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,418 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| BLUE CROSS BLUE SHIELD OF MASSACHUSETTS, INC. (National Association of Insurance Commissioners NAIC id number: 53228 ) |
| Policy contract number | 376863 |
| Policy instance | 1 |
| Insurance contract or identification number | 376863 | | Number of Individuals Covered | 188 | | Insurance policy start date | 2020-06-01 | | Insurance policy end date | 2021-05-31 | | Total amount of commissions paid to insurance broker | USD $1,247 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $1,247 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG0ACTD |
| Policy instance | 3 |
| Insurance contract or identification number | GLUG0ACTD | | Number of Individuals Covered | 158 | | Insurance policy start date | 2019-05-01 | | Insurance policy end date | 2020-04-30 | | Total amount of commissions paid to insurance broker | USD $7,924 | | Total amount of fees paid to insurance company | USD $5,787 | | 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 $97,577 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,924 | | Amount paid for insurance broker fees | 5787 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL OF MASSACHUSETTS (National Association of Insurance Commissioners NAIC id number: 52060 ) |
| Policy contract number | 19646640 |
| Policy instance | 2 |
| Insurance contract or identification number | 19646640 | | Number of Individuals Covered | 301 | | Insurance policy start date | 2019-06-01 | | Insurance policy end date | 2019-06-30 | | Total amount of commissions paid to insurance broker | USD $194 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $12,956 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $194 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| BLUE CROSS BLUE SHIELD OF MASSACHUSETTS, INC. (National Association of Insurance Commissioners NAIC id number: 53228 ) |
| Policy contract number | 376863 |
| Policy instance | 1 |
| Insurance contract or identification number | 376863 | | Number of Individuals Covered | 181 | | Insurance policy start date | 2019-06-01 | | Insurance policy end date | 2020-05-31 | | Total amount of commissions paid to insurance broker | USD $1,359 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $1,359 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG0ACTD |
| Policy instance | 3 |
| Insurance contract or identification number | GLUG0ACTD | | Number of Individuals Covered | 159 | | Insurance policy start date | 2018-05-01 | | Insurance policy end date | 2019-04-30 | | Total amount of commissions paid to insurance broker | USD $7,867 | | Total amount of fees paid to insurance company | USD $5,651 | | 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 $95,858 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,867 | | Amount paid for insurance broker fees | 5651 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL OF MASSACHUSETTS (National Association of Insurance Commissioners NAIC id number: 52060 ) |
| Policy contract number | 19646640 |
| Policy instance | 2 |
| Insurance contract or identification number | 19646640 | | Number of Individuals Covered | 301 | | Insurance policy start date | 2018-06-01 | | Insurance policy end date | 2019-05-31 | | Total amount of commissions paid to insurance broker | USD $2,311 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $154,818 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,311 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| BLUE CROSS BLUE SHIELD OF MASSACHUSETTS, INC. (National Association of Insurance Commissioners NAIC id number: 53228 ) |
| Policy contract number | 0376863 |
| Policy instance | 1 |
| Insurance contract or identification number | 0376863 | | Number of Individuals Covered | 191 | | Insurance policy start date | 2018-06-01 | | Insurance policy end date | 2019-05-31 | | Total amount of commissions paid to insurance broker | USD $1,218 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $1,218 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG0ACTD |
| Policy instance | 3 |
| Insurance contract or identification number | GLUG0ACTD | | Number of Individuals Covered | 159 | | Insurance policy start date | 2017-05-01 | | Insurance policy end date | 2018-04-30 | | Total amount of commissions paid to insurance broker | USD $7,710 | | Total amount of fees paid to insurance company | USD $5,377 | | 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 $91,103 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,710 | | Amount paid for insurance broker fees | 5377 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | BORISLOW INSURANCE AGENCY, INC. |
|
| DELTA DENTAL OF MASSACHUSETTS (National Association of Insurance Commissioners NAIC id number: 52060 ) |
| Policy contract number | 19646640 |
| Policy instance | 2 |
| Insurance contract or identification number | 19646640 | | Number of Individuals Covered | 297 | | Insurance policy start date | 2017-06-01 | | Insurance policy end date | 2018-05-31 | | Total amount of commissions paid to insurance broker | USD $2,106 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $153,470 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,106 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | BORISLOW INSURANCE AGENCY, INC. |
|
| BLUE CROSS BLUE SHIELD OF MASSACHUSETTS, INC. (National Association of Insurance Commissioners NAIC id number: 53228 ) |
| Policy contract number | 0376863 |
| Policy instance | 1 |
| Insurance contract or identification number | 0376863 | | Number of Individuals Covered | 188 | | Insurance policy start date | 2017-06-01 | | Insurance policy end date | 2018-05-31 | | Total amount of commissions paid to insurance broker | USD $1,358 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $1,358 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | BORISLOW INSURANCE AGENCY, INC. |
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