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BIG GEYSER, INC. HEALTH AND WELFARE BENEFIT PLAN. BIG GEYSER, INC. 401k Plan overview

Plan NameBIG GEYSER, INC. HEALTH AND WELFARE BENEFIT PLAN. BIG GEYSER, INC.
Plan identification number 501

BIG GEYSER, INC. HEALTH AND WELFARE BENEFIT PLAN. BIG GEYSER, INC. Benefits

401k Plan TypeWelfare Benefit
Plan Features/Benefits
  • Health (other than dental or vision)
  • Life insurance
  • Dental
  • Vision
  • Death benefits (include travel accident but not life insurance)

401k Sponsoring company profile

BIG GEYSER INC. has sponsored the creation of one or more 401k plans.

Company Name:BIG GEYSER INC.
Employer identification number (EIN):133350407
NAIC Classification:424990
NAIC Description:Other Miscellaneous Nondurable Goods Merchant Wholesalers

Additional information about BIG GEYSER INC.

Jurisdiction of Incorporation: State of Delaware Division of Corporations
Incorporation Date:
Company Identification Number: 2092044

More information about BIG GEYSER INC.

Form 5500 Filing Information

Submission information for form 5500 for 401k plan BIG GEYSER, INC. HEALTH AND WELFARE BENEFIT PLAN. BIG GEYSER, INC.

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5012022-01-01MARJORIE BARRERA2023-09-12
5012021-01-01MARJOIRE BERRERA2022-09-26
5012020-01-01ERIC CELT2021-08-05
5012019-01-01MARJORIE BARRERA2020-06-25
5012018-01-01
5012017-01-01

Plan Statistics for BIG GEYSER, INC. HEALTH AND WELFARE BENEFIT PLAN. BIG GEYSER, INC.

401k plan membership statisitcs for BIG GEYSER, INC. HEALTH AND WELFARE BENEFIT PLAN. BIG GEYSER, INC.

Measure Date Value
2022: BIG GEYSER, INC. HEALTH AND WELFARE BENEFIT PLAN. BIG GEYSER, INC. 2022 401k membership
Total participants, beginning-of-year2022-01-01170
Total number of active participants reported on line 7a of the Form 55002022-01-01175
Number of retired or separated participants receiving benefits2022-01-010
Number of other retired or separated participants entitled to future benefits2022-01-010
Total of all active and inactive participants2022-01-01175
Number of employers contributing to the scheme2022-01-010
2021: BIG GEYSER, INC. HEALTH AND WELFARE BENEFIT PLAN. BIG GEYSER, INC. 2021 401k membership
Total participants, beginning-of-year2021-01-01151
Total number of active participants reported on line 7a of the Form 55002021-01-01155
Number of retired or separated participants receiving benefits2021-01-010
Number of other retired or separated participants entitled to future benefits2021-01-010
Total of all active and inactive participants2021-01-01155
Number of employers contributing to the scheme2021-01-010
2020: BIG GEYSER, INC. HEALTH AND WELFARE BENEFIT PLAN. BIG GEYSER, INC. 2020 401k membership
Total participants, beginning-of-year2020-01-01166
Total number of active participants reported on line 7a of the Form 55002020-01-01151
Number of retired or separated participants receiving benefits2020-01-010
Number of other retired or separated participants entitled to future benefits2020-01-010
Total of all active and inactive participants2020-01-01151
Number of employers contributing to the scheme2020-01-010
2019: BIG GEYSER, INC. HEALTH AND WELFARE BENEFIT PLAN. BIG GEYSER, INC. 2019 401k membership
Total participants, beginning-of-year2019-01-01114
Total number of active participants reported on line 7a of the Form 55002019-01-01166
Number of retired or separated participants receiving benefits2019-01-012
Number of other retired or separated participants entitled to future benefits2019-01-010
Total of all active and inactive participants2019-01-01168
Number of employers contributing to the scheme2019-01-010
2018: BIG GEYSER, INC. HEALTH AND WELFARE BENEFIT PLAN. BIG GEYSER, INC. 2018 401k membership
Total participants, beginning-of-year2018-01-01108
Total number of active participants reported on line 7a of the Form 55002018-01-01112
Number of retired or separated participants receiving benefits2018-01-010
Number of other retired or separated participants entitled to future benefits2018-01-010
Total of all active and inactive participants2018-01-01112
Number of employers contributing to the scheme2018-01-010
2017: BIG GEYSER, INC. HEALTH AND WELFARE BENEFIT PLAN. BIG GEYSER, INC. 2017 401k membership
Total participants, beginning-of-year2017-01-01139
Total number of active participants reported on line 7a of the Form 55002017-01-01104
Number of retired or separated participants receiving benefits2017-01-010
Number of other retired or separated participants entitled to future benefits2017-01-010
Total of all active and inactive participants2017-01-01104

Form 5500 Responses for BIG GEYSER, INC. HEALTH AND WELFARE BENEFIT PLAN. BIG GEYSER, INC.

2022: BIG GEYSER, INC. HEALTH AND WELFARE BENEFIT PLAN. BIG GEYSER, INC. 2022 form 5500 responses
2022-01-01Type of plan entitySingle employer plan
2022-01-01Plan funding arrangement – InsuranceYes
2022-01-01Plan funding arrangement – General assets of the sponsorYes
2022-01-01Plan benefit arrangement – InsuranceYes
2022-01-01Plan benefit arrangement – General assets of the sponsorYes
2021: BIG GEYSER, INC. HEALTH AND WELFARE BENEFIT PLAN. BIG GEYSER, INC. 2021 form 5500 responses
2021-01-01Type of plan entitySingle employer plan
2021-01-01Plan funding arrangement – InsuranceYes
2021-01-01Plan funding arrangement – General assets of the sponsorYes
2021-01-01Plan benefit arrangement – InsuranceYes
2021-01-01Plan benefit arrangement – General assets of the sponsorYes
2020: BIG GEYSER, INC. HEALTH AND WELFARE BENEFIT PLAN. BIG GEYSER, INC. 2020 form 5500 responses
2020-01-01Type of plan entitySingle employer plan
2020-01-01Plan funding arrangement – InsuranceYes
2020-01-01Plan funding arrangement – General assets of the sponsorYes
2020-01-01Plan benefit arrangement – InsuranceYes
2020-01-01Plan benefit arrangement – General assets of the sponsorYes
2019: BIG GEYSER, INC. HEALTH AND WELFARE BENEFIT PLAN. BIG GEYSER, INC. 2019 form 5500 responses
2019-01-01Type of plan entitySingle employer plan
2019-01-01Plan funding arrangement – InsuranceYes
2019-01-01Plan funding arrangement – General assets of the sponsorYes
2019-01-01Plan benefit arrangement – InsuranceYes
2019-01-01Plan benefit arrangement – General assets of the sponsorYes
2018: BIG GEYSER, INC. HEALTH AND WELFARE BENEFIT PLAN. BIG GEYSER, INC. 2018 form 5500 responses
2018-01-01Type of plan entitySingle employer plan
2018-01-01Plan funding arrangement – InsuranceYes
2018-01-01Plan funding arrangement – General assets of the sponsorYes
2018-01-01Plan benefit arrangement – InsuranceYes
2018-01-01Plan benefit arrangement – General assets of the sponsorYes
2017: BIG GEYSER, INC. HEALTH AND WELFARE BENEFIT PLAN. BIG GEYSER, INC. 2017 form 5500 responses
2017-01-01Type of plan entitySingle employer plan
2017-01-01First time form 5500 has been submittedYes
2017-01-01Plan funding arrangement – InsuranceYes
2017-01-01Plan benefit arrangement – InsuranceYes

Insurance Providers Used on plan

UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number240429
Policy instance 5
Insurance contract or identification number240429
Number of Individuals Covered318
Insurance policy start date2021-12-01
Insurance policy end date2022-11-30
Total amount of commissions paid to insurance brokerUSD $85,486
Total amount of fees paid to insurance companyUSD $4,932
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Welfare Benefit Premiums Paid to CarrierUSD $2,543,809
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $79,668
Amount paid for insurance broker fees0
Insurance broker organization code?3
THE PAUL REVERE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 67598 )
Policy contract numberE4887907
Policy instance 4
Insurance contract or identification numberE4887907
Number of Individuals Covered137
Insurance policy start date2021-12-01
Insurance policy end date2022-11-30
Total amount of commissions paid to insurance brokerUSD $26,552
Total amount of fees paid to insurance companyUSD $1,876
Life Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $140,242
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $12,977
Amount paid for insurance broker fees0
Insurance broker organization code?3
Additional information about fees paid to insurance brokerFEES
THE PAUL REVERE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 67598 )
Policy contract numberE4928602
Policy instance 3
Insurance contract or identification numberE4928602
Number of Individuals Covered83
Insurance policy start date2021-12-01
Insurance policy end date2022-11-30
Total amount of commissions paid to insurance brokerUSD $17,727
Total amount of fees paid to insurance companyUSD $1,359
Life Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $75,532
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $8,908
Amount paid for insurance broker fees0
Insurance broker organization code?3
Additional information about fees paid to insurance brokerFEES
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract numberE4887907
Policy instance 2
Insurance contract or identification numberE4887907
Number of Individuals Covered1
Insurance policy start date2021-12-01
Insurance policy end date2022-11-30
Total amount of commissions paid to insurance brokerUSD $38
Total amount of fees paid to insurance companyUSD $0
Life Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $379
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $15
Amount paid for insurance broker fees0
Insurance broker organization code?3
LINCOLN LIFE AND ANNUITY CO OF NY (National Association of Insurance Commissioners NAIC id number: 62057 )
Policy contract number10227645
Policy instance 1
Insurance contract or identification number10227645
Number of Individuals Covered586
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $1,343
Total amount of fees paid to insurance companyUSD $981
Life Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $11,460
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,343
Amount paid for insurance broker fees981
Additional information about fees paid to insurance brokerOVERRIDE, BROKER BONUS
Insurance broker organization code?3
LINCOLN LIFE AND ANNUITY CO OF NY (National Association of Insurance Commissioners NAIC id number: 62057 )
Policy contract number10227645
Policy instance 1
Insurance contract or identification number10227645
Number of Individuals Covered492
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $987
Total amount of fees paid to insurance companyUSD $765
Life Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $7,975
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $987
Amount paid for insurance broker fees765
Additional information about fees paid to insurance brokerOVERRIDES AND BROKER BONUS
Insurance broker organization code?3
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract numberE4887907
Policy instance 2
Insurance contract or identification numberE4887907
Number of Individuals Covered1
Insurance policy start date2020-12-01
Insurance policy end date2021-11-30
Total amount of commissions paid to insurance brokerUSD $101
Total amount of fees paid to insurance companyUSD $7
Life Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $410
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $43
Amount paid for insurance broker fees0
Insurance broker organization code?3
Additional information about fees paid to insurance brokerFEES
THE PAUL REVERE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 67598 )
Policy contract numberE4928602
Policy instance 3
Insurance contract or identification numberE4928602
Number of Individuals Covered56
Insurance policy start date2020-12-01
Insurance policy end date2021-11-30
Total amount of commissions paid to insurance brokerUSD $13,068
Total amount of fees paid to insurance companyUSD $500
Life Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $56,268
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6,523
Amount paid for insurance broker fees0
Insurance broker organization code?3
Additional information about fees paid to insurance brokerFEES
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number910218
Policy instance 4
Insurance contract or identification number910218
Number of Individuals Covered299
Insurance policy start date2020-12-01
Insurance policy end date2021-11-30
Total amount of commissions paid to insurance brokerUSD $90,045
Total amount of fees paid to insurance companyUSD $4,156
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Welfare Benefit Premiums Paid to CarrierUSD $2,580,574
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $84,417
Amount paid for insurance broker fees0
Insurance broker organization code?3
Additional information about fees paid to insurance brokerBONUS
THE PAUL REVERE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 67598 )
Policy contract numberE4928602
Policy instance 5
Insurance contract or identification numberE4928602
Number of Individuals Covered110
Insurance policy start date2019-12-01
Insurance policy end date2020-11-30
Total amount of commissions paid to insurance brokerUSD $26,859
Total amount of fees paid to insurance companyUSD $1,217
Life Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $109,944
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $13,287
Amount paid for insurance broker fees0
Insurance broker organization code?3
Additional information about fees paid to insurance brokerFEES
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract numberE4887907
Policy instance 4
Insurance contract or identification numberE4887907
Number of Individuals Covered2
Insurance policy start date2019-12-01
Insurance policy end date2020-11-30
Total amount of commissions paid to insurance brokerUSD $288
Total amount of fees paid to insurance companyUSD $40
Life Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $694
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $125
Amount paid for insurance broker fees0
Insurance broker organization code?3
Additional information about fees paid to insurance brokerFEES
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number910218
Policy instance 3
Insurance contract or identification number910218
Number of Individuals Covered259
Insurance policy start date2019-12-01
Insurance policy end date2020-11-30
Total amount of commissions paid to insurance brokerUSD $2,706
Total amount of fees paid to insurance companyUSD $4,403
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $134,957
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $0
Amount paid for insurance broker fees4403
Additional information about fees paid to insurance brokerBONUS
Insurance broker organization code?3
LINCOLN LIFE AND ANNUITY CO OF NY (National Association of Insurance Commissioners NAIC id number: 62057 )
Policy contract number10227645
Policy instance 2
Insurance contract or identification number10227645
Number of Individuals Covered410
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $1,161
Total amount of fees paid to insurance companyUSD $522
Life Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $9,557
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,161
Amount paid for insurance broker fees522
Additional information about fees paid to insurance brokerOVERRIDES BROKER BONUS
Insurance broker organization code?3
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract numberCG02101
Policy instance 1
Insurance contract or identification numberCG02101
Number of Individuals Covered271
Insurance policy start date2019-12-01
Insurance policy end date2020-11-30
Total amount of commissions paid to insurance brokerUSD $76,124
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $2,001,263
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $76,124
Amount paid for insurance broker fees0
Insurance broker organization code?3
THE PAUL REVERE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 67598 )
Policy contract numberE4928602
Policy instance 6
Insurance contract or identification numberE4928602
Number of Individuals Covered50
Insurance policy start date2018-12-01
Insurance policy end date2019-11-30
Total amount of commissions paid to insurance brokerUSD $10,084
Total amount of fees paid to insurance companyUSD $360
Life Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $40,287
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,113
Amount paid for insurance broker fees0
Insurance broker organization code?3
Additional information about fees paid to insurance brokerFEES
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract numberE4887907
Policy instance 5
Insurance contract or identification numberE4887907
Number of Individuals Covered85
Insurance policy start date2018-12-01
Insurance policy end date2019-11-30
Total amount of commissions paid to insurance brokerUSD $55
Total amount of fees paid to insurance companyUSD $11
Life Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $437
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $28
Amount paid for insurance broker fees10
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number910218
Policy instance 4
Insurance contract or identification number910218
Number of Individuals Covered292
Insurance policy start date2018-12-01
Insurance policy end date2019-11-30
Total amount of commissions paid to insurance brokerUSD $10,435
Total amount of fees paid to insurance companyUSD $4,072
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $117,284
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,447
Amount paid for insurance broker fees4072
Additional information about fees paid to insurance brokerBONUS
Insurance broker organization code?3
LINCOLN LIFE AND ANNUITY CO OF NY (National Association of Insurance Commissioners NAIC id number: 62057 )
Policy contract number10227645
Policy instance 3
Insurance contract or identification number10227645
Number of Individuals Covered448
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $1,133
Total amount of fees paid to insurance companyUSD $848
Life Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $9,304
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,133
Amount paid for insurance broker fees848
Additional information about fees paid to insurance brokerOVERRIDES BROKER BONUS
Insurance broker organization code?3
OXFORD HEALTH INSURANCE, INC (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract numberCG02101
Policy instance 2
Insurance contract or identification numberCG02101
Number of Individuals Covered221
Insurance policy start date2018-12-01
Insurance policy end date2019-11-30
Total amount of commissions paid to insurance brokerUSD $75,458
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,759,904
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $75,458
Amount paid for insurance broker fees0
Insurance broker organization code?3
HIP HEALTH PLANS (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number1101062001
Policy instance 1
Insurance contract or identification number1101062001
Number of Individuals Covered10
Insurance policy start date2018-12-01
Insurance policy end date2019-11-30
Total amount of commissions paid to insurance brokerUSD $2,424
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $63,011
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $2,424
Amount paid for insurance broker fees0
Insurance broker organization code?3
HIP HEALTH PLANS (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number1101062001
Policy instance 1
Insurance contract or identification number1101062001
Number of Individuals Covered12
Insurance policy start date2017-12-01
Insurance policy end date2018-11-30
Total amount of commissions paid to insurance brokerUSD $3,507
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $91,191
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $3,507
Amount paid for insurance broker fees0
Insurance broker organization code?3
OXFORD HEALTH INSURANCE, INC (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract numberCG02101
Policy instance 2
Insurance contract or identification numberCG02101
Number of Individuals Covered205
Insurance policy start date2017-12-01
Insurance policy end date2018-11-30
Total amount of commissions paid to insurance brokerUSD $62,972
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,473,447
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $62,972
Amount paid for insurance broker fees0
Insurance broker organization code?3
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number910218
Policy instance 3
Insurance contract or identification number910218
Number of Individuals Covered212
Insurance policy start date2017-12-01
Insurance policy end date2018-11-30
Total amount of commissions paid to insurance brokerUSD $11,565
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $92,959
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,648
Amount paid for insurance broker fees0
Insurance broker organization code?3
LINCOLN LIFE AND ANNUITY CO OF NY (National Association of Insurance Commissioners NAIC id number: 62057 )
Policy contract number10227645
Policy instance 4
Insurance contract or identification number10227645
Number of Individuals Covered402
Insurance policy start date2018-02-01
Insurance policy end date2018-06-30
Total amount of commissions paid to insurance brokerUSD $919
Total amount of fees paid to insurance companyUSD $705
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 AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $7,355
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $919
Amount paid for insurance broker fees705
Additional information about fees paid to insurance brokerOVERRIDES BROKER BONUS, OVERRIDES
Insurance broker organization code?3
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract numberC7425820
Policy instance 5
Insurance contract or identification numberC7425820
Number of Individuals Covered33
Insurance policy start date2017-12-01
Insurance policy end date2018-11-30
Total amount of commissions paid to insurance brokerUSD $468
Total amount of fees paid to insurance companyUSD $1,067
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 AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $1,001
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $57
Amount paid for insurance broker fees988
Insurance broker organization code?3
Additional information about fees paid to insurance brokerFEES
LINCOLN LIFE AND ANNUITY CO OF NY (National Association of Insurance Commissioners NAIC id number: 62057 )
Policy contract number10227645
Policy instance 4
Insurance contract or identification number10227645
Number of Individuals Covered376
Insurance policy start date2017-07-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $408
Total amount of fees paid to insurance companyUSD $143
Life Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $3,472
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $334
Amount paid for insurance broker fees143
Additional information about fees paid to insurance brokerOVERRIDES
Insurance broker organization code?3
Insurance broker nameSTERLING AND STERLING LLC
LINCOLN LIFE AND ANNUITY CO OF NY (National Association of Insurance Commissioners NAIC id number: 62057 )
Policy contract number10227645
Policy instance 3
Insurance contract or identification number10227645
Number of Individuals Covered345
Insurance policy start date2017-02-01
Insurance policy end date2017-06-30
Total amount of commissions paid to insurance brokerUSD $348
Total amount of fees paid to insurance companyUSD $0
Life Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $2,399
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $348
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameSTERLING AND STERLING INC
OXFORD HEALTH INSURANCE, INC (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract numberCG02101
Policy instance 2
Insurance contract or identification numberCG02101
Number of Individuals Covered202
Insurance policy start date2016-12-01
Insurance policy end date2017-11-30
Total amount of commissions paid to insurance brokerUSD $48,039
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,428,370
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $48,039
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameSTERLING AND STERLING LLC
HIP HEALTH PLANS (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number1010168 000
Policy instance 1
Insurance contract or identification number1010168 000
Number of Individuals Covered8
Insurance policy start date2016-12-01
Insurance policy end date2017-11-30
Total amount of commissions paid to insurance brokerUSD $2,596
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $67,504
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $2,596
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameDAVID STERLING

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