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VISITING NURSE SERVICE INC. GROUP TERM ADD PLAN 401k Plan overview

Plan NameVISITING NURSE SERVICE INC. GROUP TERM ADD PLAN
Plan identification number 501

VISITING NURSE SERVICE INC. GROUP TERM ADD PLAN Benefits

401k Plan TypeWelfare Benefit
Plan Features/Benefits
  • Life insurance
  • Temporary disability (accident and sickness)
  • Long-term disability cover
  • Death benefits (include travel accident but not life insurance)

401k Sponsoring company profile

VISITING NURSE SERVICE AND HOSPICE OF SUFFOLK, INC. has sponsored the creation of one or more 401k plans.

Company Name:VISITING NURSE SERVICE AND HOSPICE OF SUFFOLK, INC.
Employer identification number (EIN):111722477
NAIC Classification:621610
NAIC Description:Home Health Care Services

Additional information about VISITING NURSE SERVICE AND HOSPICE OF SUFFOLK, INC.

Jurisdiction of Incorporation: New York Department of State
Incorporation Date: 1952-03-13
Company Identification Number: 77585
Legal Registered Office Address: 505 MAIN STREET
Suffolk
NORTHPORT
United States of America (USA)
11768

More information about VISITING NURSE SERVICE AND HOSPICE OF SUFFOLK, INC.

Form 5500 Filing Information

Submission information for form 5500 for 401k plan VISITING NURSE SERVICE INC. GROUP TERM ADD PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5012017-03-01
5012016-03-01SCOTT WILLIAMS
5012015-03-01STEVEN MOLLER STEVEN MOLLER2017-01-23
5012014-03-01STEVEN MOLLER STEVEN MOLLER2015-12-07
5012013-03-01STEVEN MOLLER STEVEN MOLLER2015-01-29
5012012-03-01LINDA M. TAYLOR

Plan Statistics for VISITING NURSE SERVICE INC. GROUP TERM ADD PLAN

401k plan membership statisitcs for VISITING NURSE SERVICE INC. GROUP TERM ADD PLAN

Measure Date Value
2017: VISITING NURSE SERVICE INC. GROUP TERM ADD PLAN 2017 401k membership
Total participants, beginning-of-year2017-03-01149
Total number of active participants reported on line 7a of the Form 55002017-03-010
Number of retired or separated participants receiving benefits2017-03-010
Number of other retired or separated participants entitled to future benefits2017-03-010
Total of all active and inactive participants2017-03-010
2016: VISITING NURSE SERVICE INC. GROUP TERM ADD PLAN 2016 401k membership
Total participants, beginning-of-year2016-03-01151
Total number of active participants reported on line 7a of the Form 55002016-03-01149
Total of all active and inactive participants2016-03-01149
Total participants2016-03-01149
2015: VISITING NURSE SERVICE INC. GROUP TERM ADD PLAN 2015 401k membership
Total participants, beginning-of-year2015-03-01153
Total number of active participants reported on line 7a of the Form 55002015-03-01151
Total of all active and inactive participants2015-03-01151
Total participants2015-03-01151
2014: VISITING NURSE SERVICE INC. GROUP TERM ADD PLAN 2014 401k membership
Total participants, beginning-of-year2014-03-01138
Total number of active participants reported on line 7a of the Form 55002014-03-01153
Total of all active and inactive participants2014-03-01153
Total participants2014-03-01153
2013: VISITING NURSE SERVICE INC. GROUP TERM ADD PLAN 2013 401k membership
Total participants, beginning-of-year2013-03-01135
Total number of active participants reported on line 7a of the Form 55002013-03-01138
Total of all active and inactive participants2013-03-01138
Total participants2013-03-01138
2012: VISITING NURSE SERVICE INC. GROUP TERM ADD PLAN 2012 401k membership
Total participants, beginning-of-year2012-03-01137
Total number of active participants reported on line 7a of the Form 55002012-03-01135
Total of all active and inactive participants2012-03-01135

Form 5500 Responses for VISITING NURSE SERVICE INC. GROUP TERM ADD PLAN

2017: VISITING NURSE SERVICE INC. GROUP TERM ADD PLAN 2017 form 5500 responses
2017-03-01Type of plan entitySingle employer plan
2017-03-01Submission has been amendedNo
2017-03-01This submission is the final filingYes
2017-03-01This return/report is a short plan year return/report (less than 12 months)No
2017-03-01Plan is a collectively bargained planNo
2017-03-01Plan funding arrangement – InsuranceYes
2017-03-01Plan benefit arrangement – InsuranceYes
2016: VISITING NURSE SERVICE INC. GROUP TERM ADD PLAN 2016 form 5500 responses
2016-03-01Type of plan entitySingle employer plan
2016-03-01Submission has been amendedNo
2016-03-01This submission is the final filingNo
2016-03-01This return/report is a short plan year return/report (less than 12 months)No
2016-03-01Plan is a collectively bargained planNo
2016-03-01Plan funding arrangement – InsuranceYes
2016-03-01Plan benefit arrangement – InsuranceYes
2015: VISITING NURSE SERVICE INC. GROUP TERM ADD PLAN 2015 form 5500 responses
2015-03-01Type of plan entitySingle employer plan
2015-03-01Submission has been amendedNo
2015-03-01This submission is the final filingNo
2015-03-01This return/report is a short plan year return/report (less than 12 months)No
2015-03-01Plan is a collectively bargained planNo
2015-03-01Plan funding arrangement – InsuranceYes
2015-03-01Plan benefit arrangement – InsuranceYes
2014: VISITING NURSE SERVICE INC. GROUP TERM ADD PLAN 2014 form 5500 responses
2014-03-01Type of plan entitySingle employer plan
2014-03-01Submission has been amendedNo
2014-03-01This submission is the final filingNo
2014-03-01This return/report is a short plan year return/report (less than 12 months)No
2014-03-01Plan is a collectively bargained planNo
2014-03-01Plan funding arrangement – InsuranceYes
2014-03-01Plan benefit arrangement – InsuranceYes
2013: VISITING NURSE SERVICE INC. GROUP TERM ADD PLAN 2013 form 5500 responses
2013-03-01Type of plan entitySingle employer plan
2013-03-01Submission has been amendedNo
2013-03-01This submission is the final filingNo
2013-03-01This return/report is a short plan year return/report (less than 12 months)No
2013-03-01Plan is a collectively bargained planNo
2013-03-01Plan funding arrangement – InsuranceYes
2013-03-01Plan benefit arrangement – InsuranceYes
2012: VISITING NURSE SERVICE INC. GROUP TERM ADD PLAN 2012 form 5500 responses
2012-03-01Type of plan entitySingle employer plan
2012-03-01Plan funding arrangement – InsuranceYes
2012-03-01Plan benefit arrangement – InsuranceYes

Insurance Providers Used on plan

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 71412 )
Policy contract numberG000AL9A
Policy instance 3
Insurance contract or identification numberG000AL9A
Number of Individuals Covered135
Insurance policy start date2017-04-01
Insurance policy end date2018-02-28
Total amount of commissions paid to insurance brokerUSD $105
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating 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
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 $1,054
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $105
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerCOMMISSIONS
Insurance broker organization code?3
Insurance broker nameUSI INSURANCE SERVICES LLC
COMPANION LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62243 )
Policy contract numberG000AL9A
Policy instance 2
Insurance contract or identification numberG000AL9A
Number of Individuals Covered135
Insurance policy start date2017-04-01
Insurance policy end date2018-02-28
Total amount of commissions paid to insurance brokerUSD $1,017
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating 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
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 $10,173
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,017
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerCOMMISSIONS
Insurance broker organization code?3
Insurance broker nameUSI INSURANCE SERVICES LLC
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 71412 )
Policy contract numberG000AL9A
Policy instance 1
Insurance contract or identification numberG000AL9A
Number of Individuals Covered135
Insurance policy start date2017-04-01
Insurance policy end date2018-02-28
Total amount of commissions paid to insurance brokerUSD $3,359
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating 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 $27,187
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,359
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerCOMMISSIONS
Insurance broker organization code?3
Insurance broker nameUSI INSURANCE SERVICES LLC
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 71412 )
Policy contract numberG000AL9A
Policy instance 3
Insurance contract or identification numberG000AL9A
Number of Individuals Covered151
Insurance policy start date2015-04-01
Insurance policy end date2016-04-01
Total amount of commissions paid to insurance brokerUSD $115
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 $1,151
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $115
Additional information about fees paid to insurance brokerAGENT OR BROKER OF RECORD
Insurance broker organization code?3
Insurance broker nameUSI INSURANCE SERVICES LLC
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 71412 )
Policy contract numberG000AL9A
Policy instance 2
Insurance contract or identification numberG000AL9A
Number of Individuals Covered151
Insurance policy start date2015-04-01
Insurance policy end date2016-04-01
Total amount of commissions paid to insurance brokerUSD $3,365
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 $27,292
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,365
Additional information about fees paid to insurance brokerAGENT OF BROKER OF RECORD
Insurance broker organization code?3
Insurance broker nameUSI INSURANCE SERVICES LLC
COMPANION LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62243 )
Policy contract numberG000AL9A
Policy instance 1
Insurance contract or identification numberG000AL9A
Number of Individuals Covered151
Insurance policy start date2015-04-01
Insurance policy end date2016-04-01
Total amount of commissions paid to insurance brokerUSD $842
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
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 $8,425
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $845
Additional information about fees paid to insurance brokerAGENT OF BROKER OF RECORD
Insurance broker organization code?3
Insurance broker nameUSI INSURANCE SERVICES LLC
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 71412 )
Policy contract numberG000AL9A
Policy instance 3
Insurance contract or identification numberG000AL9A
Number of Individuals Covered153
Insurance policy start date2014-04-01
Insurance policy end date2015-04-01
Total amount of commissions paid to insurance brokerUSD $115
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 $1,154
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $115
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerAGENT OR BROKER OF RECORD
Insurance broker nameUSI INSURANCE SERVICES LLC
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 71412 )
Policy contract numberG000AL9A
Policy instance 2
Insurance contract or identification numberG000AL9A
Number of Individuals Covered153
Insurance policy start date2014-04-01
Insurance policy end date2015-04-01
Total amount of commissions paid to insurance brokerUSD $3,365
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 $27,302
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,365
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerAGENT OF BROKER OF RECORD
Insurance broker nameUSI INSURANCE SERVICES LLC
COMPANION LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62243 )
Policy contract numberG000AL9A
Policy instance 1
Insurance contract or identification numberG000AL9A
Number of Individuals Covered153
Insurance policy start date2014-04-01
Insurance policy end date2015-04-01
Total amount of commissions paid to insurance brokerUSD $845
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
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 $8,477
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $845
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerAGENT OF BROKER OF RECORD
Insurance broker nameUSI INSURANCE SERVICES LLC
COMPANION LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62243 )
Policy contract numberG000AL9A
Policy instance 3
Insurance contract or identification numberG000AL9A
Number of Individuals Covered138
Insurance policy start date2013-04-01
Insurance policy end date2014-04-01
Total amount of commissions paid to insurance brokerUSD $632
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
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 $6,320
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $632
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerAGENT OR BROKER OF RECORD AND OTHER COMPENSATION
Insurance broker nameUSI INSURANCE SERVICES LLC
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 71412 )
Policy contract numberG000AL9A
Policy instance 2
Insurance contract or identification numberG000AL9A
Number of Individuals Covered138
Insurance policy start date2013-04-01
Insurance policy end date2014-04-01
Total amount of commissions paid to insurance brokerUSD $3,238
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 $24,877
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,238
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerAGENT OR BROKER OF RECORD AND OTHER COMPENSATION
Insurance broker nameUSI INSURANCE SERVICES LLC
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 71412 )
Policy contract numberG000AL9A
Policy instance 1
Insurance contract or identification numberG000AL9A
Number of Individuals Covered138
Insurance policy start date2013-04-01
Insurance policy end date2014-04-01
Total amount of commissions paid to insurance brokerUSD $106
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 $1,055
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $106
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerAGENT OR BROKER OF RECORD AND OTHER COMPENSATION
Insurance broker nameUSI INSURANCE SERVICES LLC
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 71412 )
Policy contract numberG000AL9A
Policy instance 4
Insurance contract or identification numberG000AL9A
Number of Individuals Covered135
Insurance policy start date2012-04-01
Insurance policy end date2013-04-01
Total amount of commissions paid to insurance brokerUSD $105
Total amount of fees paid to insurance companyUSD $18
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Temporary Disability Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $105
Amount paid for insurance broker fees18
Additional information about fees paid to insurance brokerAGENT OR BROKER OF RECORD AND OTHER COMPENSATION
Insurance broker nameUSI INSURANCE SERVICES LLC
COMPANION LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62243 )
Policy contract numberG000AL9A
Policy instance 3
Insurance contract or identification numberG000AL9A
Number of Individuals Covered135
Insurance policy start date2012-04-01
Insurance policy end date2013-04-01
Total amount of commissions paid to insurance brokerUSD $631
Total amount of fees paid to insurance companyUSD $110
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Life Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $631
Amount paid for insurance broker fees110
Additional information about fees paid to insurance brokerAGENT OR BROKER OF RECORD AND OTHER COMPENSATION
Insurance broker nameUSI INSURANCE SERVICES LLC
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 71412 )
Policy contract numberG000AL9A
Policy instance 2
Insurance contract or identification numberG000AL9A
Number of Individuals Covered135
Insurance policy start date2012-04-01
Insurance policy end date2013-04-01
Total amount of commissions paid to insurance brokerUSD $3,222
Total amount of fees paid to insurance companyUSD $425
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Long Term Disability Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,222
Amount paid for insurance broker fees425
Additional information about fees paid to insurance brokerAGENT OR BROKER OF RECORD AND OTHER COMPENSATION
Insurance broker nameUSI INSURANCE SERVICES LLC
DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 )
Policy contract numberFNYH893289
Policy instance 1
Insurance contract or identification numberFNYH893289
Number of Individuals Covered133
Insurance policy start date2012-01-01
Insurance policy end date2012-12-31
Total amount of commissions paid to insurance brokerUSD $1,440
Total amount of fees paid to insurance companyUSD $340
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,440
Amount paid for insurance broker fees340
Insurance broker nameEMERSON REID & COMPANY, INC.

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