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THE MIDDLESEX CORPORATION EMPLOYEE BENEFITS PLAN 401k Plan overview

Plan NameTHE MIDDLESEX CORPORATION EMPLOYEE BENEFITS PLAN
Plan identification number 501

THE MIDDLESEX CORPORATION EMPLOYEE BENEFITS PLAN Benefits

401k Plan TypeWelfare Benefit
Plan Features/Benefits
  • Health (other than dental or vision)
  • Life insurance
  • Dental
  • Vision
  • Temporary disability (accident and sickness)
  • Long-term disability cover
  • Death benefits (include travel accident but not life insurance)
  • Other welfare benefit cover

401k Sponsoring company profile

THE MIDDLESEX CORPORATION has sponsored the creation of one or more 401k plans.

Company Name:THE MIDDLESEX CORPORATION
Employer identification number (EIN):042534615
NAIC Classification:237310
NAIC Description:Highway, Street, and Bridge Construction

Additional information about THE MIDDLESEX CORPORATION

Jurisdiction of Incorporation: Washington Secretary of State Corporations Division
Incorporation Date: 1971-08-26
Company Identification Number: 601485619
Legal Registered Office Address: 5321 43RD AVENUE CT NW

GIG HARBOR
United States of America (USA)
983358169

More information about THE MIDDLESEX CORPORATION

Form 5500 Filing Information

Submission information for form 5500 for 401k plan THE MIDDLESEX CORPORATION EMPLOYEE BENEFITS PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5012022-07-01TOM DONARUMA2023-12-13
5012021-07-01THOMAS DONARUMA2022-12-01
5012020-07-01TOM DONARUMA2021-11-12
5012019-07-01THOMAS DONARUMA2020-12-23
5012018-07-01TOM DONARUMA2020-01-06
5012017-07-01
5012016-07-01
5012015-07-01TOM DONARUMA
5012014-07-01THOMAS E DONARUMAN
5012013-07-01TONY SPADORCIA
5012012-08-01ROBERT JACOBSON
5012011-08-01ROBERT JACOBSON
5012011-03-01ROBERT JACOBSON
5012009-03-01ROBERT JACOBSON
5012009-03-01ROBERT JACOBSON

Plan Statistics for THE MIDDLESEX CORPORATION EMPLOYEE BENEFITS PLAN

401k plan membership statisitcs for THE MIDDLESEX CORPORATION EMPLOYEE BENEFITS PLAN

Measure Date Value
2022: THE MIDDLESEX CORPORATION EMPLOYEE BENEFITS PLAN 2022 401k membership
Total participants, beginning-of-year2022-07-01903
Total number of active participants reported on line 7a of the Form 55002022-07-01903
Number of retired or separated participants receiving benefits2022-07-010
Number of other retired or separated participants entitled to future benefits2022-07-010
Total of all active and inactive participants2022-07-01903
Number of employers contributing to the scheme2022-07-010
2021: THE MIDDLESEX CORPORATION EMPLOYEE BENEFITS PLAN 2021 401k membership
Total participants, beginning-of-year2021-07-01879
Total number of active participants reported on line 7a of the Form 55002021-07-01903
Number of retired or separated participants receiving benefits2021-07-010
Number of other retired or separated participants entitled to future benefits2021-07-010
Total of all active and inactive participants2021-07-01903
Number of employers contributing to the scheme2021-07-010
2020: THE MIDDLESEX CORPORATION EMPLOYEE BENEFITS PLAN 2020 401k membership
Total participants, beginning-of-year2020-07-01963
Total number of active participants reported on line 7a of the Form 55002020-07-01879
Number of retired or separated participants receiving benefits2020-07-010
Number of other retired or separated participants entitled to future benefits2020-07-010
Total of all active and inactive participants2020-07-01879
Number of employers contributing to the scheme2020-07-010
2019: THE MIDDLESEX CORPORATION EMPLOYEE BENEFITS PLAN 2019 401k membership
Total participants, beginning-of-year2019-07-01444
Total number of active participants reported on line 7a of the Form 55002019-07-01963
Number of retired or separated participants receiving benefits2019-07-010
Number of other retired or separated participants entitled to future benefits2019-07-010
Total of all active and inactive participants2019-07-01963
Number of employers contributing to the scheme2019-07-010
2018: THE MIDDLESEX CORPORATION EMPLOYEE BENEFITS PLAN 2018 401k membership
Total participants, beginning-of-year2018-07-01941
Total number of active participants reported on line 7a of the Form 55002018-07-01444
Number of retired or separated participants receiving benefits2018-07-010
Number of other retired or separated participants entitled to future benefits2018-07-010
Total of all active and inactive participants2018-07-01444
Number of employers contributing to the scheme2018-07-010
2017: THE MIDDLESEX CORPORATION EMPLOYEE BENEFITS PLAN 2017 401k membership
Total participants, beginning-of-year2017-07-01791
Total number of active participants reported on line 7a of the Form 55002017-07-01937
Number of retired or separated participants receiving benefits2017-07-014
Number of other retired or separated participants entitled to future benefits2017-07-010
Total of all active and inactive participants2017-07-01941
Number of employers contributing to the scheme2017-07-010
2016: THE MIDDLESEX CORPORATION EMPLOYEE BENEFITS PLAN 2016 401k membership
Total participants, beginning-of-year2016-07-01412
Total number of active participants reported on line 7a of the Form 55002016-07-01788
Number of retired or separated participants receiving benefits2016-07-013
Number of other retired or separated participants entitled to future benefits2016-07-010
Total of all active and inactive participants2016-07-01791
2015: THE MIDDLESEX CORPORATION EMPLOYEE BENEFITS PLAN 2015 401k membership
Total participants, beginning-of-year2015-07-01306
Total number of active participants reported on line 7a of the Form 55002015-07-01406
Number of retired or separated participants receiving benefits2015-07-016
Number of other retired or separated participants entitled to future benefits2015-07-010
Total of all active and inactive participants2015-07-01412
2014: THE MIDDLESEX CORPORATION EMPLOYEE BENEFITS PLAN 2014 401k membership
Total participants, beginning-of-year2014-07-01297
Total number of active participants reported on line 7a of the Form 55002014-07-01306
Number of retired or separated participants receiving benefits2014-07-010
Number of other retired or separated participants entitled to future benefits2014-07-010
Total of all active and inactive participants2014-07-01306
2013: THE MIDDLESEX CORPORATION EMPLOYEE BENEFITS PLAN 2013 401k membership
Total participants, beginning-of-year2013-07-01445
Total number of active participants reported on line 7a of the Form 55002013-07-01445
Number of retired or separated participants receiving benefits2013-07-010
Number of other retired or separated participants entitled to future benefits2013-07-010
Total of all active and inactive participants2013-07-01445
2012: THE MIDDLESEX CORPORATION EMPLOYEE BENEFITS PLAN 2012 401k membership
Total participants, beginning-of-year2012-08-01384
Total number of active participants reported on line 7a of the Form 55002012-08-01432
Number of retired or separated participants receiving benefits2012-08-010
Number of other retired or separated participants entitled to future benefits2012-08-010
Total of all active and inactive participants2012-08-01432
2011: THE MIDDLESEX CORPORATION EMPLOYEE BENEFITS PLAN 2011 401k membership
Total participants, beginning-of-year2011-08-01370
Total number of active participants reported on line 7a of the Form 55002011-08-01384
Number of retired or separated participants receiving benefits2011-08-0120
Number of other retired or separated participants entitled to future benefits2011-08-010
Total of all active and inactive participants2011-08-01404
Total participants, beginning-of-year2011-03-01354
Total number of active participants reported on line 7a of the Form 55002011-03-01366
Number of retired or separated participants receiving benefits2011-03-014
Number of other retired or separated participants entitled to future benefits2011-03-010
Total of all active and inactive participants2011-03-01370
2009: THE MIDDLESEX CORPORATION EMPLOYEE BENEFITS PLAN 2009 401k membership
Total participants, beginning-of-year2009-03-01280
Total number of active participants reported on line 7a of the Form 55002009-03-01315
Number of retired or separated participants receiving benefits2009-03-019
Number of other retired or separated participants entitled to future benefits2009-03-010
Total of all active and inactive participants2009-03-01324

Form 5500 Responses for THE MIDDLESEX CORPORATION EMPLOYEE BENEFITS PLAN

2022: THE MIDDLESEX CORPORATION EMPLOYEE BENEFITS PLAN 2022 form 5500 responses
2022-07-01Type of plan entitySingle employer plan
2022-07-01Plan funding arrangement – InsuranceYes
2022-07-01Plan funding arrangement – General assets of the sponsorYes
2022-07-01Plan benefit arrangement – InsuranceYes
2022-07-01Plan benefit arrangement – General assets of the sponsorYes
2021: THE MIDDLESEX CORPORATION EMPLOYEE BENEFITS PLAN 2021 form 5500 responses
2021-07-01Type of plan entitySingle employer plan
2021-07-01Plan funding arrangement – InsuranceYes
2021-07-01Plan funding arrangement – General assets of the sponsorYes
2021-07-01Plan benefit arrangement – InsuranceYes
2021-07-01Plan benefit arrangement – General assets of the sponsorYes
2020: THE MIDDLESEX CORPORATION EMPLOYEE BENEFITS PLAN 2020 form 5500 responses
2020-07-01Type of plan entitySingle employer plan
2020-07-01Plan funding arrangement – InsuranceYes
2020-07-01Plan funding arrangement – General assets of the sponsorYes
2020-07-01Plan benefit arrangement – InsuranceYes
2020-07-01Plan benefit arrangement – General assets of the sponsorYes
2019: THE MIDDLESEX CORPORATION EMPLOYEE BENEFITS PLAN 2019 form 5500 responses
2019-07-01Type of plan entitySingle employer plan
2019-07-01Plan funding arrangement – InsuranceYes
2019-07-01Plan funding arrangement – General assets of the sponsorYes
2019-07-01Plan benefit arrangement – InsuranceYes
2019-07-01Plan benefit arrangement – General assets of the sponsorYes
2018: THE MIDDLESEX CORPORATION EMPLOYEE BENEFITS PLAN 2018 form 5500 responses
2018-07-01Type of plan entitySingle employer plan
2018-07-01Plan funding arrangement – InsuranceYes
2018-07-01Plan funding arrangement – General assets of the sponsorYes
2018-07-01Plan benefit arrangement – InsuranceYes
2018-07-01Plan benefit arrangement – General assets of the sponsorYes
2017: THE MIDDLESEX CORPORATION EMPLOYEE BENEFITS PLAN 2017 form 5500 responses
2017-07-01Type of plan entitySingle employer plan
2017-07-01Plan funding arrangement – InsuranceYes
2017-07-01Plan funding arrangement – General assets of the sponsorYes
2017-07-01Plan benefit arrangement – InsuranceYes
2017-07-01Plan benefit arrangement – General assets of the sponsorYes
2016: THE MIDDLESEX CORPORATION EMPLOYEE BENEFITS PLAN 2016 form 5500 responses
2016-07-01Type of plan entitySingle employer plan
2016-07-01Submission has been amendedNo
2016-07-01This submission is the final filingNo
2016-07-01This return/report is a short plan year return/report (less than 12 months)No
2016-07-01Plan is a collectively bargained planNo
2016-07-01Plan funding arrangement – InsuranceYes
2016-07-01Plan funding arrangement – General assets of the sponsorYes
2016-07-01Plan benefit arrangement – InsuranceYes
2016-07-01Plan benefit arrangement – General assets of the sponsorYes
2015: THE MIDDLESEX CORPORATION EMPLOYEE BENEFITS PLAN 2015 form 5500 responses
2015-07-01Type of plan entitySingle employer plan
2015-07-01Submission has been amendedNo
2015-07-01This submission is the final filingNo
2015-07-01This return/report is a short plan year return/report (less than 12 months)No
2015-07-01Plan is a collectively bargained planNo
2015-07-01Plan funding arrangement – InsuranceYes
2015-07-01Plan funding arrangement – General assets of the sponsorYes
2015-07-01Plan benefit arrangement – InsuranceYes
2015-07-01Plan benefit arrangement – General assets of the sponsorYes
2014: THE MIDDLESEX CORPORATION EMPLOYEE BENEFITS PLAN 2014 form 5500 responses
2014-07-01Type of plan entitySingle employer plan
2014-07-01Submission has been amendedNo
2014-07-01This submission is the final filingNo
2014-07-01This return/report is a short plan year return/report (less than 12 months)No
2014-07-01Plan is a collectively bargained planNo
2014-07-01Plan funding arrangement – InsuranceYes
2014-07-01Plan funding arrangement – General assets of the sponsorYes
2014-07-01Plan benefit arrangement – InsuranceYes
2014-07-01Plan benefit arrangement – General assets of the sponsorYes
2013: THE MIDDLESEX CORPORATION EMPLOYEE BENEFITS PLAN 2013 form 5500 responses
2013-07-01Type of plan entitySingle employer plan
2013-07-01Submission has been amendedNo
2013-07-01This submission is the final filingNo
2013-07-01This return/report is a short plan year return/report (less than 12 months)No
2013-07-01Plan is a collectively bargained planNo
2013-07-01Plan funding arrangement – InsuranceYes
2013-07-01Plan funding arrangement – General assets of the sponsorYes
2013-07-01Plan benefit arrangement – InsuranceYes
2013-07-01Plan benefit arrangement – General assets of the sponsorYes
2012: THE MIDDLESEX CORPORATION EMPLOYEE BENEFITS PLAN 2012 form 5500 responses
2012-08-01Type of plan entitySingle employer plan
2012-08-01Submission has been amendedNo
2012-08-01This submission is the final filingNo
2012-08-01This return/report is a short plan year return/report (less than 12 months)Yes
2012-08-01Plan is a collectively bargained planNo
2012-08-01Plan funding arrangement – InsuranceYes
2012-08-01Plan funding arrangement – General assets of the sponsorYes
2012-08-01Plan benefit arrangement – InsuranceYes
2012-08-01Plan benefit arrangement – General assets of the sponsorYes
2011: THE MIDDLESEX CORPORATION EMPLOYEE BENEFITS PLAN 2011 form 5500 responses
2011-08-01Type of plan entitySingle employer plan
2011-08-01Submission has been amendedNo
2011-08-01This submission is the final filingNo
2011-08-01This return/report is a short plan year return/report (less than 12 months)No
2011-08-01Plan is a collectively bargained planNo
2011-08-01Plan funding arrangement – InsuranceYes
2011-08-01Plan funding arrangement – General assets of the sponsorYes
2011-08-01Plan benefit arrangement – InsuranceYes
2011-08-01Plan benefit arrangement – General assets of the sponsorYes
2011-03-01Type of plan entitySingle employer plan
2011-03-01Submission has been amendedNo
2011-03-01This submission is the final filingNo
2011-03-01This return/report is a short plan year return/report (less than 12 months)Yes
2011-03-01Plan is a collectively bargained planNo
2011-03-01Plan funding arrangement – InsuranceYes
2011-03-01Plan funding arrangement – General assets of the sponsorYes
2011-03-01Plan benefit arrangement – InsuranceYes
2011-03-01Plan benefit arrangement – General assets of the sponsorYes
2009: THE MIDDLESEX CORPORATION EMPLOYEE BENEFITS PLAN 2009 form 5500 responses
2009-03-01Type of plan entitySingle employer plan
2009-03-01Submission has been amendedNo
2009-03-01This submission is the final filingNo
2009-03-01This return/report is a short plan year return/report (less than 12 months)No
2009-03-01Plan is a collectively bargained planNo
2009-03-01Plan funding arrangement – InsuranceYes
2009-03-01Plan funding arrangement – General assets of the sponsorYes
2009-03-01Plan benefit arrangement – InsuranceYes
2009-03-01Plan benefit arrangement – General assets of the sponsorYes

Insurance Providers Used on plan

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number805485G
Policy instance 2
Insurance contract or identification number805485G
Number of Individuals Covered750
Insurance policy start date2022-07-01
Insurance policy end date2023-06-30
Total amount of commissions paid to insurance brokerUSD $53,652
Total amount of fees paid to insurance companyUSD $7,829
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT, ACCIDENT, CRITICAL ILLNESS
Welfare Benefit Premiums Paid to CarrierUSD $524,238
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $31,889
Amount paid for insurance broker fees7829
Additional information about fees paid to insurance brokerBONUS
Insurance broker organization code?3
NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 )
Policy contract number38509
Policy instance 1
Insurance contract or identification number38509
Number of Individuals Covered385
Insurance policy start date2022-07-01
Insurance policy end date2023-06-30
Total amount of commissions paid to insurance brokerUSD $4,498
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $43,777
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,496
Amount paid for insurance broker fees0
Insurance broker organization code?3
COMPSYCH (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract numberEAP
Policy instance 3
Insurance contract or identification numberEAP
Number of Individuals Covered903
Insurance policy start date2022-07-01
Insurance policy end date2023-06-30
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedEMPLOYEE ASSISTANCE PROGRAM
Welfare Benefit Premiums Paid to CarrierUSD $14,845
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
COMPSYCH (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract numberEAP
Policy instance 3
Insurance contract or identification numberEAP
Number of Individuals Covered903
Insurance policy start date2021-07-01
Insurance policy end date2022-06-30
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedEMPLOYEE ASSISTANCE PROGRAM
Welfare Benefit Premiums Paid to CarrierUSD $14,845
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
NATIONAL GUARDIAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 66583 )
Policy contract number38509
Policy instance 1
Insurance contract or identification number38509
Number of Individuals Covered418
Insurance policy start date2021-07-01
Insurance policy end date2022-06-30
Total amount of commissions paid to insurance brokerUSD $5,643
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $56,431
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,643
Amount paid for insurance broker fees0
Insurance broker organization code?3
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number805485G
Policy instance 2
Insurance contract or identification number805485G
Number of Individuals Covered756
Insurance policy start date2021-07-01
Insurance policy end date2022-06-30
Total amount of commissions paid to insurance brokerUSD $63,071
Total amount of fees paid to insurance companyUSD $8,113
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT, ACCIDENT, CRITICAL ILLNESS
Welfare Benefit Premiums Paid to CarrierUSD $573,207
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $43,825
Amount paid for insurance broker fees8113
Additional information about fees paid to insurance brokerBONUS PAID
Insurance broker organization code?3
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number805485G
Policy instance 2
Insurance contract or identification number805485G
Number of Individuals Covered879
Insurance policy start date2020-07-01
Insurance policy end date2021-06-30
Total amount of commissions paid to insurance brokerUSD $39,507
Total amount of fees paid to insurance companyUSD $2,229
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT, ACCIDENT, CRITICAL ILLNESS
Welfare Benefit Premiums Paid to CarrierUSD $468,678
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $23,814
Amount paid for insurance broker fees0
Insurance broker organization code?3
Additional information about fees paid to insurance brokerBONUS
NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 )
Policy contract number38509
Policy instance 1
Insurance contract or identification number38509
Number of Individuals Covered453
Insurance policy start date2020-07-01
Insurance policy end date2021-06-30
Total amount of commissions paid to insurance brokerUSD $5,328
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $53,280
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,328
Amount paid for insurance broker fees0
Insurance broker organization code?3
NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 )
Policy contract number38509
Policy instance 1
Insurance contract or identification number38509
Number of Individuals Covered439
Insurance policy start date2019-07-01
Insurance policy end date2020-06-30
Total amount of commissions paid to insurance brokerUSD $4,035
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $40,354
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $4,035
Amount paid for insurance broker fees0
Insurance broker organization code?3
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number870085
Policy instance 3
Insurance contract or identification number870085
Number of Individuals Covered963
Insurance policy start date2019-07-01
Insurance policy end date2020-06-30
Total amount of commissions paid to insurance brokerUSD $24,251
Total amount of fees paid to insurance companyUSD $33,159
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $328,522
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $24,251
Amount paid for insurance broker fees33159
Additional information about fees paid to insurance brokerDIRECT COMPENSATION INDIRECT COMPENSATION
Insurance broker organization code?3
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number884302G
Policy instance 2
Insurance contract or identification number884302G
Number of Individuals Covered242
Insurance policy start date2019-07-01
Insurance policy end date2020-06-30
Total amount of commissions paid to insurance brokerUSD $65,779
Total amount of fees paid to insurance companyUSD $540
Temporary Disability Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENT, CRITICAL ILLNESS
Welfare Benefit Premiums Paid to CarrierUSD $186,913
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $39,468
Amount paid for insurance broker fees0
Insurance broker organization code?3
Additional information about fees paid to insurance brokerBONUS
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number10069351001
Policy instance 2
Insurance contract or identification number10069351001
Number of Individuals Covered762
Insurance policy start date2018-07-01
Insurance policy end date2019-06-30
Total amount of commissions paid to insurance brokerUSD $3,276
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $29,236
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,276
Amount paid for insurance broker fees0
Insurance broker organization code?3
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number884302G
Policy instance 3
Insurance contract or identification number884302G
Number of Individuals Covered218
Insurance policy start date2018-07-01
Insurance policy end date2019-06-30
Total amount of commissions paid to insurance brokerUSD $60,533
Total amount of fees paid to insurance companyUSD $0
Temporary Disability Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENT, CRITICAL ILLNESS
Welfare Benefit Premiums Paid to CarrierUSD $100,087
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $36,320
Amount paid for insurance broker fees0
Insurance broker organization code?3
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number870085
Policy instance 1
Insurance contract or identification number870085
Number of Individuals Covered1043
Insurance policy start date2018-07-01
Insurance policy end date2019-06-30
Total amount of commissions paid to insurance brokerUSD $17,740
Total amount of fees paid to insurance companyUSD $181,058
Health Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $6,870,520
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $17,740
Amount paid for insurance broker fees181058
Additional information about fees paid to insurance broker2018 PPP MEDICAL RETENTION INDIRECT COMPENSATION DIRECT COMPENSATION
Insurance broker organization code?3
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract numberE4515516
Policy instance 4
Insurance contract or identification numberE4515516
Number of Individuals Covered11
Insurance policy start date2017-07-01
Insurance policy end date2018-06-30
Total amount of commissions paid to insurance brokerUSD $888
Total amount of fees paid to insurance companyUSD $0
Temporary Disability Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENT, CRITICAL ILLNESS, CANCER
Welfare Benefit Premiums Paid to CarrierUSD $10,259
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $349
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameC LAMBERT, INC.
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract numberE4515250
Policy instance 3
Insurance contract or identification numberE4515250
Number of Individuals Covered102
Insurance policy start date2017-07-01
Insurance policy end date2018-06-30
Total amount of commissions paid to insurance brokerUSD $17,884
Total amount of fees paid to insurance companyUSD $1,455
Temporary Disability Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENT, CRITICAL ILLNESS, CANCER
Welfare Benefit Premiums Paid to CarrierUSD $140,429
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6,990
Amount paid for insurance broker fees851
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
Insurance broker nameDAVID L. FLEURY
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number10069351001
Policy instance 2
Insurance contract or identification number10069351001
Number of Individuals Covered745
Insurance policy start date2017-07-01
Insurance policy end date2018-06-30
Total amount of commissions paid to insurance brokerUSD $3,824
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $34,930
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,824
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameGALLAGHER BENEFIT SERVICES, INC.
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number870085
Policy instance 1
Insurance contract or identification number870085
Number of Individuals Covered937
Insurance policy start date2017-07-01
Insurance policy end date2018-06-30
Total amount of commissions paid to insurance brokerUSD $15,152
Total amount of fees paid to insurance companyUSD $189,459
Health Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $5,571,854
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $15,152
Amount paid for insurance broker fees189459
Additional information about fees paid to insurance brokerMA LOCAL MARKET MEDICAL BONUS 2017 PPP ENGAGEMENT CREDIT NEW BUS GROUP INS DIRECT/INDIRECT COMPENSATION
Insurance broker organization code?3
Insurance broker nameGALLAGHER BENEFIT SERVICES, INC.
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number10176560
Policy instance 2
Insurance contract or identification number10176560
Number of Individuals Covered609
Insurance policy start date2015-07-01
Insurance policy end date2016-06-30
Total amount of commissions paid to insurance brokerUSD $10,438
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $159,096
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $10,438
Insurance broker organization code?3
Insurance broker nameGALLAGHER BENEFIT SERVICES, INC.
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number708074/905479
Policy instance 1
Insurance contract or identification number708074/905479
Number of Individuals Covered624
Insurance policy start date2015-07-01
Insurance policy end date2016-06-30
Total amount of commissions paid to insurance brokerUSD $130,638
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $3,981,401
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $127,764
Insurance broker organization code?3
Insurance broker namePINNACLE INSURANCE AGENCY
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number10176560
Policy instance 4
Insurance contract or identification number10176560
Number of Individuals Covered482
Insurance policy start date2014-07-01
Insurance policy end date2015-06-30
Total amount of commissions paid to insurance brokerUSD $10,164
Total amount of fees paid to insurance companyUSD $4,021
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $136,840
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $10,013
Amount paid for insurance broker fees4021
Additional information about fees paid to insurance brokerBROKER BONUS
Insurance broker organization code?3
Insurance broker nameGALLAGHER BENEFIT SERVICES, INC.
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number611419
Policy instance 2
Insurance contract or identification number611419
Number of Individuals Covered252
Insurance policy start date2014-01-01
Insurance policy end date2014-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $30,418
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $946,431
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Amount paid for insurance broker fees30418
Additional information about fees paid to insurance brokerBENEFIT ADVISOR FEES
Insurance broker organization code?3
Insurance broker namePINNACLE INSURANCE AGENCY, INC.
BLUE CROSS BLUE SHIELD OF MASSACHUSETTS, INC. (National Association of Insurance Commissioners NAIC id number: 53228 )
Policy contract number4933195
Policy instance 1
Insurance contract or identification number4933195
Number of Individuals Covered340
Insurance policy start date2014-07-01
Insurance policy end date2015-06-30
Total amount of commissions paid to insurance brokerUSD $33,827
Total amount of fees paid to insurance companyUSD $11,815
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $31,161
Amount paid for insurance broker fees11815
Additional information about fees paid to insurance brokerBONUS PERSISTENY COMMISSIONS
Insurance broker organization code?3
Insurance broker nameGALLAGHER BENEFITS SERVICES, INC.
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number708074
Policy instance 3
Insurance contract or identification number708074
Number of Individuals Covered198
Insurance policy start date2014-07-01
Insurance policy end date2015-06-30
Total amount of commissions paid to insurance brokerUSD $2,368
Total amount of fees paid to insurance companyUSD $97
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $26,898
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,174
Amount paid for insurance broker fees97
Additional information about fees paid to insurance brokerSERVICE FEE AGREEMENT
Insurance broker organization code?3
Insurance broker nameGALLAGHER BENEFIT SERVICES, INC.
BLUE CROSS BLUE SHIELD OF MASSACHUSETTS, INC. (National Association of Insurance Commissioners NAIC id number: 53228 )
Policy contract number4933195
Policy instance 1
Insurance contract or identification number4933195
Number of Individuals Covered137
Insurance policy start date2013-07-01
Insurance policy end date2014-06-30
Total amount of commissions paid to insurance brokerUSD $34,951
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $18,405
Insurance broker organization code?3
Insurance broker nameB P BENEFITS, LLC
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number708074
Policy instance 3
Insurance contract or identification number708074
Number of Individuals Covered254
Insurance policy start date2013-07-01
Insurance policy end date2014-06-30
Total amount of commissions paid to insurance brokerUSD $2,027
Total amount of fees paid to insurance companyUSD $47,965
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $1,572,521
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,027
Amount paid for insurance broker fees47965
Additional information about fees paid to insurance brokerSERVICE FEE AGREEMENT
Insurance broker organization code?3
Insurance broker namePINNACLE INSURANCE AGENCY
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number10176560,1,2
Policy instance 2
Insurance contract or identification number10176560,1,2
Number of Individuals Covered445
Insurance policy start date2013-07-01
Insurance policy end date2014-06-30
Total amount of commissions paid to insurance brokerUSD $10,074
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH & DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $133,389
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $10,074
Insurance broker organization code?3
Insurance broker namePINNACLE INSURANCE AGENCY
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number0708074
Policy instance 1
Insurance contract or identification number0708074
Number of Individuals Covered254
Insurance policy start date2012-08-01
Insurance policy end date2013-06-30
Total amount of commissions paid to insurance brokerUSD $39,912
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $1,292,263
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $39,912
Insurance broker organization code?3
Insurance broker namePINNACLE INSURANCE AGENCY
BLUE CROSS BLUE SHIELD OF MASSACHUSETTS, INC. (National Association of Insurance Commissioners NAIC id number: 53228 )
Policy contract number4933195
Policy instance 2
Insurance contract or identification number4933195
Number of Individuals Covered369
Insurance policy start date2012-08-01
Insurance policy end date2013-06-30
Total amount of commissions paid to insurance brokerUSD $30,710
Total amount of fees paid to insurance companyUSD $7,672
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $30,710
Amount paid for insurance broker fees7672
Additional information about fees paid to insurance brokerOTHER COMMISSION
Insurance broker organization code?3
Insurance broker namePINNACLE INSURANCE AGENCY INC
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract numberG 162480
Policy instance 5
Insurance contract or identification numberG 162480
Number of Individuals Covered136
Insurance policy start date2012-08-01
Insurance policy end date2013-06-30
Total amount of commissions paid to insurance brokerUSD $3,203
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $40,058
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,203
Insurance broker organization code?3
Insurance broker namePINNACLE INSURANCE AGENCY INC
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract numberLTD 121109
Policy instance 4
Insurance contract or identification numberLTD 121109
Number of Individuals Covered154
Insurance policy start date2012-08-01
Insurance policy end date2013-06-30
Total amount of commissions paid to insurance brokerUSD $5,264
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $52,641
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,264
Insurance broker organization code?3
Insurance broker namePINNACLE INSURANCE AGENCY INC
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract numberGL 147469
Policy instance 3
Insurance contract or identification numberGL 147469
Number of Individuals Covered402
Insurance policy start date2012-08-01
Insurance policy end date2013-06-30
Total amount of commissions paid to insurance brokerUSD $4,262
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&D
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $30,100
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,262
Insurance broker organization code?3
Insurance broker namePINNACLE INSURANE AGENCY INC
BLUE CROSS BLUE SHIELD OF MASSACHUSETTS, INC. (National Association of Insurance Commissioners NAIC id number: 53228 )
Policy contract number4933195
Policy instance 1
Insurance contract or identification number4933195
Number of Individuals Covered123
Insurance policy start date2011-08-01
Insurance policy end date2012-07-31
Total amount of commissions paid to insurance brokerUSD $27,631
Total amount of fees paid to insurance companyUSD $8,816
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract number121109
Policy instance 5
Insurance contract or identification number121109
Number of Individuals Covered177
Insurance policy start date2011-08-01
Insurance policy end date2012-07-31
Total amount of commissions paid to insurance brokerUSD $5,195
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $51,948
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number0708074
Policy instance 2
Insurance contract or identification number0708074
Number of Individuals Covered254
Insurance policy start date2011-08-01
Insurance policy end date2012-07-31
Total amount of commissions paid to insurance brokerUSD $44,108
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $1,444,001
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number00396377
Policy instance 3
Insurance contract or identification number00396377
Number of Individuals Covered268
Insurance policy start date2011-08-01
Insurance policy end date2012-07-31
Total amount of commissions paid to insurance brokerUSD $6,385
Total amount of fees paid to insurance companyUSD $1,217
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $18,948
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract number147469
Policy instance 4
Insurance contract or identification number147469
Number of Individuals Covered384
Insurance policy start date2011-08-01
Insurance policy end date2012-07-31
Total amount of commissions paid to insurance brokerUSD $2,237
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&D
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $14,916
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 number4933195
Policy instance 1
Insurance contract or identification number4933195
Number of Individuals Covered109
Insurance policy start date2010-08-01
Insurance policy end date2011-07-31
Total amount of commissions paid to insurance brokerUSD $25,760
Total amount of fees paid to insurance companyUSD $10,973
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $1,285,789
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract number121109
Policy instance 5
Insurance contract or identification number121109
Number of Individuals Covered122
Insurance policy start date2010-08-01
Insurance policy end date2011-07-31
Total amount of commissions paid to insurance brokerUSD $5,548
Total amount of fees paid to insurance companyUSD $610
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $48,171
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number0708074
Policy instance 4
Insurance contract or identification number0708074
Number of Individuals Covered254
Insurance policy start date2010-08-01
Insurance policy end date2011-07-31
Total amount of commissions paid to insurance brokerUSD $32,747
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $1,091,589
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract number147469
Policy instance 3
Insurance contract or identification number147469
Number of Individuals Covered366
Insurance policy start date2010-08-01
Insurance policy end date2011-07-31
Total amount of commissions paid to insurance brokerUSD $2,464
Total amount of fees paid to insurance companyUSD $192
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&D
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $14,909
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number00396377
Policy instance 2
Insurance contract or identification number00396377
Number of Individuals Covered235
Insurance policy start date2010-08-01
Insurance policy end date2011-07-31
Total amount of commissions paid to insurance brokerUSD $6,066
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $17,613
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 number4933195
Policy instance 1
Insurance contract or identification number4933195
Number of Individuals Covered110
Insurance policy start date2009-08-01
Insurance policy end date2010-07-31
Total amount of commissions paid to insurance brokerUSD $25,993
Total amount of fees paid to insurance companyUSD $11,726
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $25,993
Amount paid for insurance broker fees11726
Additional information about fees paid to insurance brokerBONUS
Insurance broker organization code?3
Insurance broker nameWEST RIDGE INSURANCE AGENCY, INC.
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number0708074
Policy instance 5
Insurance contract or identification number0708074
Number of Individuals Covered233
Insurance policy start date2009-08-01
Insurance policy end date2010-07-31
Total amount of commissions paid to insurance brokerUSD $34,150
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $1,138,345
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $34,150
Insurance broker organization code?3
Insurance broker nameWEST RIDGE INSURANCE AGENCY, INC.
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number00396377
Policy instance 2
Insurance contract or identification number00396377
Number of Individuals Covered208
Insurance policy start date2009-08-01
Insurance policy end date2010-07-31
Total amount of commissions paid to insurance brokerUSD $5,916
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $15,558
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,916
Insurance broker organization code?3
Insurance broker nameWEST RIDGE INSURANCE AGENCY, INC.
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number93394-1
Policy instance 3
Insurance contract or identification number93394-1
Number of Individuals Covered342
Insurance policy start date2010-03-01
Insurance policy end date2010-07-31
Total amount of commissions paid to insurance brokerUSD $754
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH & DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $6,287
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $754
Insurance broker organization code?3
Insurance broker nameWEST RIDGE INSURANCE AGENCY, INC.
STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )
Policy contract number123628
Policy instance 4
Insurance contract or identification number123628
Number of Individuals Covered90
Insurance policy start date2009-08-01
Insurance policy end date2010-07-31
Total amount of commissions paid to insurance brokerUSD $4,772
Total amount of fees paid to insurance companyUSD $420
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,772
Amount paid for insurance broker fees420
Additional information about fees paid to insurance brokerBONUS
Insurance broker organization code?3
Insurance broker nameWEST RIDGE INSURANCE AGENCY, INC.

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