EVANS BANK, NA has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan EVANS NATIONAL BANK HEALTH & WELFARE PLAN
Measure | Date | Value |
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2022: EVANS NATIONAL BANK HEALTH & WELFARE PLAN 2022 401k membership |
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Total participants, beginning-of-year | 2022-01-01 | 398 |
Total number of active participants reported on line 7a of the Form 5500 | 2022-01-01 | 378 |
Number of retired or separated participants receiving benefits | 2022-01-01 | 5 |
Number of other retired or separated participants entitled to future benefits | 2022-01-01 | 0 |
Total of all active and inactive participants | 2022-01-01 | 383 |
2021: EVANS NATIONAL BANK HEALTH & WELFARE PLAN 2021 401k membership |
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Total participants, beginning-of-year | 2021-01-01 | 405 |
Total number of active participants reported on line 7a of the Form 5500 | 2021-01-01 | 391 |
Number of retired or separated participants receiving benefits | 2021-01-01 | 7 |
Number of other retired or separated participants entitled to future benefits | 2021-01-01 | 5 |
Total of all active and inactive participants | 2021-01-01 | 403 |
2020: EVANS NATIONAL BANK HEALTH & WELFARE PLAN 2020 401k membership |
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Total participants, beginning-of-year | 2020-01-01 | 329 |
Total number of active participants reported on line 7a of the Form 5500 | 2020-01-01 | 385 |
Number of retired or separated participants receiving benefits | 2020-01-01 | 10 |
Number of other retired or separated participants entitled to future benefits | 2020-01-01 | 10 |
Total of all active and inactive participants | 2020-01-01 | 405 |
2019: EVANS NATIONAL BANK HEALTH & WELFARE PLAN 2019 401k membership |
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Total participants, beginning-of-year | 2019-01-01 | 310 |
Total number of active participants reported on line 7a of the Form 5500 | 2019-01-01 | 302 |
Number of retired or separated participants receiving benefits | 2019-01-01 | 4 |
Number of other retired or separated participants entitled to future benefits | 2019-01-01 | 5 |
Total of all active and inactive participants | 2019-01-01 | 311 |
2018: EVANS NATIONAL BANK HEALTH & WELFARE PLAN 2018 401k membership |
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Total participants, beginning-of-year | 2018-01-01 | 294 |
Total number of active participants reported on line 7a of the Form 5500 | 2018-01-01 | 294 |
Number of retired or separated participants receiving benefits | 2018-01-01 | 7 |
Number of other retired or separated participants entitled to future benefits | 2018-01-01 | 10 |
Total of all active and inactive participants | 2018-01-01 | 311 |
2017: EVANS NATIONAL BANK HEALTH & WELFARE PLAN 2017 401k membership |
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Total participants, beginning-of-year | 2017-01-01 | 263 |
Total number of active participants reported on line 7a of the Form 5500 | 2017-01-01 | 269 |
Number of retired or separated participants receiving benefits | 2017-01-01 | 5 |
Number of other retired or separated participants entitled to future benefits | 2017-01-01 | 9 |
Total of all active and inactive participants | 2017-01-01 | 283 |
2016: EVANS NATIONAL BANK HEALTH & WELFARE PLAN 2016 401k membership |
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Total participants, beginning-of-year | 2016-01-01 | 160 |
Total number of active participants reported on line 7a of the Form 5500 | 2016-01-01 | 149 |
Number of retired or separated participants receiving benefits | 2016-01-01 | 5 |
Number of other retired or separated participants entitled to future benefits | 2016-01-01 | 0 |
Total of all active and inactive participants | 2016-01-01 | 154 |
2015: EVANS NATIONAL BANK HEALTH & WELFARE PLAN 2015 401k membership |
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Total participants, beginning-of-year | 2015-01-01 | 196 |
Total number of active participants reported on line 7a of the Form 5500 | 2015-01-01 | 229 |
Number of retired or separated participants receiving benefits | 2015-01-01 | 10 |
Total of all active and inactive participants | 2015-01-01 | 239 |
2014: EVANS NATIONAL BANK HEALTH & WELFARE PLAN 2014 401k membership |
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Total participants, beginning-of-year | 2014-01-01 | 202 |
Total number of active participants reported on line 7a of the Form 5500 | 2014-01-01 | 190 |
Number of retired or separated participants receiving benefits | 2014-01-01 | 12 |
Number of other retired or separated participants entitled to future benefits | 2014-01-01 | 0 |
Total of all active and inactive participants | 2014-01-01 | 202 |
2013: EVANS NATIONAL BANK HEALTH & WELFARE PLAN 2013 401k membership |
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Total participants, beginning-of-year | 2013-01-01 | 210 |
Total number of active participants reported on line 7a of the Form 5500 | 2013-01-01 | 196 |
Number of retired or separated participants receiving benefits | 2013-01-01 | 10 |
Number of other retired or separated participants entitled to future benefits | 2013-01-01 | 0 |
Total of all active and inactive participants | 2013-01-01 | 206 |
2012: EVANS NATIONAL BANK HEALTH & WELFARE PLAN 2012 401k membership |
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Total participants, beginning-of-year | 2012-01-01 | 251 |
Total number of active participants reported on line 7a of the Form 5500 | 2012-01-01 | 240 |
Number of retired or separated participants receiving benefits | 2012-01-01 | 5 |
Number of other retired or separated participants entitled to future benefits | 2012-01-01 | 6 |
Total of all active and inactive participants | 2012-01-01 | 251 |
2011: EVANS NATIONAL BANK HEALTH & WELFARE PLAN 2011 401k membership |
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Total participants, beginning-of-year | 2011-01-01 | 224 |
Total number of active participants reported on line 7a of the Form 5500 | 2011-01-01 | 229 |
Number of retired or separated participants receiving benefits | 2011-01-01 | 8 |
Number of other retired or separated participants entitled to future benefits | 2011-01-01 | 0 |
Total of all active and inactive participants | 2011-01-01 | 237 |
2010: EVANS NATIONAL BANK HEALTH & WELFARE PLAN 2010 401k membership |
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Total participants, beginning-of-year | 2010-01-01 | 225 |
Total number of active participants reported on line 7a of the Form 5500 | 2010-01-01 | 218 |
Number of retired or separated participants receiving benefits | 2010-01-01 | 6 |
Number of other retired or separated participants entitled to future benefits | 2010-01-01 | 0 |
Total of all active and inactive participants | 2010-01-01 | 224 |
2009: EVANS NATIONAL BANK HEALTH & WELFARE PLAN 2009 401k membership |
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Total participants, beginning-of-year | 2009-01-01 | 203 |
Total number of active participants reported on line 7a of the Form 5500 | 2009-01-01 | 218 |
Number of retired or separated participants receiving benefits | 2009-01-01 | 7 |
Number of other retired or separated participants entitled to future benefits | 2009-01-01 | 0 |
Total of all active and inactive participants | 2009-01-01 | 225 |
2008: EVANS NATIONAL BANK HEALTH & WELFARE PLAN 2008 401k membership |
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Total participants, beginning-of-year | 2008-01-01 | 202 |
Total number of active participants reported on line 7a of the Form 5500 | 2008-01-01 | 193 |
Number of retired or separated participants receiving benefits | 2008-01-01 | 11 |
Number of other retired or separated participants entitled to future benefits | 2008-01-01 | 0 |
Total of all active and inactive participants | 2008-01-01 | 204 |
2022: EVANS NATIONAL BANK HEALTH & WELFARE PLAN 2022 form 5500 responses |
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2022-01-01 | Type of plan entity | Single employer plan |
2022-01-01 | Plan funding arrangement – Insurance | Yes |
2022-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2022-01-01 | Plan benefit arrangement – Insurance | Yes |
2022-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
2021: EVANS NATIONAL BANK HEALTH & WELFARE PLAN 2021 form 5500 responses |
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2021-01-01 | Type of plan entity | Single employer plan |
2021-01-01 | Plan funding arrangement – Insurance | Yes |
2021-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2021-01-01 | Plan benefit arrangement – Insurance | Yes |
2021-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
2020: EVANS NATIONAL BANK HEALTH & WELFARE PLAN 2020 form 5500 responses |
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2020-01-01 | Type of plan entity | Single employer plan |
2020-01-01 | Plan funding arrangement – Insurance | Yes |
2020-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2020-01-01 | Plan benefit arrangement – Insurance | Yes |
2020-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
2019: EVANS NATIONAL BANK HEALTH & WELFARE PLAN 2019 form 5500 responses |
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2019-01-01 | Type of plan entity | Single employer plan |
2019-01-01 | Plan funding arrangement – Insurance | Yes |
2019-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2019-01-01 | Plan benefit arrangement – Insurance | Yes |
2019-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
2018: EVANS NATIONAL BANK HEALTH & WELFARE PLAN 2018 form 5500 responses |
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2018-01-01 | Type of plan entity | Single employer plan |
2018-01-01 | Plan funding arrangement – Insurance | Yes |
2018-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2018-01-01 | Plan benefit arrangement – Insurance | Yes |
2018-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
2017: EVANS NATIONAL BANK HEALTH & WELFARE PLAN 2017 form 5500 responses |
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2017-01-01 | Type of plan entity | Single employer plan |
2017-01-01 | Plan funding arrangement – Insurance | Yes |
2017-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2017-01-01 | Plan benefit arrangement – Insurance | Yes |
2017-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
2016: EVANS NATIONAL BANK HEALTH & WELFARE PLAN 2016 form 5500 responses |
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2016-01-01 | Type of plan entity | Single employer plan |
2016-01-01 | Plan funding arrangement – Insurance | Yes |
2016-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2016-01-01 | Plan benefit arrangement – Insurance | Yes |
2016-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
2015: EVANS NATIONAL BANK HEALTH & WELFARE PLAN 2015 form 5500 responses |
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2015-01-01 | Type of plan entity | Single employer plan |
2015-01-01 | Plan funding arrangement – Insurance | Yes |
2015-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2015-01-01 | Plan benefit arrangement – Insurance | Yes |
2015-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
2014: EVANS NATIONAL BANK HEALTH & WELFARE PLAN 2014 form 5500 responses |
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2014-01-01 | Type of plan entity | Single employer plan |
2014-01-01 | Plan funding arrangement – Insurance | Yes |
2014-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2014-01-01 | Plan benefit arrangement – Insurance | Yes |
2014-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
2013: EVANS NATIONAL BANK HEALTH & WELFARE PLAN 2013 form 5500 responses |
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2013-01-01 | Type of plan entity | Single employer plan |
2013-01-01 | Plan funding arrangement – Insurance | Yes |
2013-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2013-01-01 | Plan benefit arrangement – Insurance | Yes |
2013-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
2012: EVANS NATIONAL BANK HEALTH & WELFARE PLAN 2012 form 5500 responses |
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2012-01-01 | Type of plan entity | Single employer plan |
2012-01-01 | Plan funding arrangement – Insurance | Yes |
2012-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2012-01-01 | Plan benefit arrangement – Insurance | Yes |
2012-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
2011: EVANS NATIONAL BANK HEALTH & WELFARE PLAN 2011 form 5500 responses |
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2011-01-01 | Type of plan entity | Single employer plan |
2011-01-01 | Submission has been amended | Yes |
2011-01-01 | Plan funding arrangement – Insurance | Yes |
2011-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2011-01-01 | Plan benefit arrangement – Insurance | Yes |
2011-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
2010: EVANS NATIONAL BANK HEALTH & WELFARE PLAN 2010 form 5500 responses |
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2010-01-01 | Type of plan entity | Single employer plan |
2010-01-01 | Submission has been amended | No |
2010-01-01 | This submission is the final filing | No |
2010-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2010-01-01 | Plan is a collectively bargained plan | No |
2010-01-01 | Plan funding arrangement – Insurance | Yes |
2010-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2010-01-01 | Plan benefit arrangement – Insurance | Yes |
2010-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
2009: EVANS NATIONAL BANK HEALTH & WELFARE PLAN 2009 form 5500 responses |
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2009-01-01 | Type of plan entity | Single employer plan |
2009-01-01 | Submission has been amended | No |
2009-01-01 | This submission is the final filing | No |
2009-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2009-01-01 | Plan is a collectively bargained plan | No |
2009-01-01 | Plan funding arrangement – Insurance | Yes |
2009-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2009-01-01 | Plan benefit arrangement – Insurance | Yes |
2009-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
2008: EVANS NATIONAL BANK HEALTH & WELFARE PLAN 2008 form 5500 responses |
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2008-01-01 | Type of plan entity | Single employer plan |
2008-01-01 | Submission has been amended | No |
2008-01-01 | This submission is the final filing | No |
2008-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2008-01-01 | Plan is a collectively bargained plan | No |
2008-01-01 | Plan funding arrangement – Insurance | Yes |
2008-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2008-01-01 | Plan benefit arrangement – Insurance | Yes |
2008-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
Policy contract number | 892413G |
Policy instance | 4 |
Insurance contract or identification number | 892413G | Number of Individuals Covered | 377 | Insurance policy start date | 2022-01-01 | Insurance policy end date | 2022-12-31 | Total amount of commissions paid to insurance broker | USD $13,378 | Total amount of fees paid to insurance company | USD $0 | Life Insurance Welfare Benefit | Yes | Long Term Disability Insurance Welfare Benefit | Yes | Other welfare benefits provided | AD&D | Welfare Benefit Premiums Paid to Carrier | USD $140,400 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $13,378 | Insurance broker organization code? | 3 |
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THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
Policy contract number | 00028742 |
Policy instance | 1 |
Insurance contract or identification number | 00028742 | Number of Individuals Covered | 257 | Insurance policy start date | 2022-01-01 | Insurance policy end date | 2022-12-31 | Total amount of commissions paid to insurance broker | USD $6,096 | Total amount of fees paid to insurance company | USD $2,339 | Dental Insurance Welfare Benefit | Yes | Vision Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $155,268 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $6,096 | Amount paid for insurance broker fees | 2339 | Additional information about fees paid to insurance broker | BROKER FEES | Insurance broker organization code? | 3 |
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HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
Policy contract number | 729849D |
Policy instance | 3 |
Insurance contract or identification number | 729849D | Number of Individuals Covered | 381 | Insurance policy start date | 2022-01-01 | Insurance policy end date | 2022-12-31 | Total amount of commissions paid to insurance broker | USD $8,661 | Total amount of fees paid to insurance company | USD $0 | Temporary Disability Insurance Welfare Benefit | Yes | Other welfare benefits provided | PFL | Welfare Benefit Premiums Paid to Carrier | USD $178,632 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $8,661 | Insurance broker organization code? | 3 |
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EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 ) |
Policy contract number | 041537 |
Policy instance | 2 |
Insurance contract or identification number | 041537 | Number of Individuals Covered | 243 | Insurance policy start date | 2022-01-01 | Insurance policy end date | 2022-12-31 | Total amount of commissions paid to insurance broker | USD $67,940 | Total amount of fees paid to insurance company | USD $0 | Health Insurance Welfare Benefit | Yes | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $67,940 | Insurance broker organization code? | 3 |
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HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
Policy contract number | 892413G |
Policy instance | 4 |
Insurance contract or identification number | 892413G | Number of Individuals Covered | 388 | Insurance policy start date | 2021-01-01 | Insurance policy end date | 2021-12-31 | Total amount of commissions paid to insurance broker | USD $13,056 | Total amount of fees paid to insurance company | USD $8,936 | Life Insurance Welfare Benefit | Yes | Long Term Disability Insurance Welfare Benefit | Yes | Other welfare benefits provided | AD&D | Welfare Benefit Premiums Paid to Carrier | USD $140,942 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $13,056 | Amount paid for insurance broker fees | 8936 | Additional information about fees paid to insurance broker | OTHER COMMISSIONS | Insurance broker organization code? | 3 |
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SOLSTICE HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 13971 ) |
Policy contract number | 14461 |
Policy instance | 1 |
Insurance contract or identification number | 14461 | Number of Individuals Covered | 524 | Insurance policy start date | 2021-01-01 | Insurance policy end date | 2021-12-31 | Total amount of commissions paid to insurance broker | USD $11,859 | Total amount of fees paid to insurance company | USD $0 | Dental Insurance Welfare Benefit | Yes | Vision Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $118,588 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $11,859 | Insurance broker organization code? | 3 |
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HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
Policy contract number | 729849D |
Policy instance | 3 |
Insurance contract or identification number | 729849D | Number of Individuals Covered | 383 | Insurance policy start date | 2021-01-01 | Insurance policy end date | 2021-12-31 | Total amount of commissions paid to insurance broker | USD $6,376 | Total amount of fees paid to insurance company | USD $0 | Temporary Disability Insurance Welfare Benefit | Yes | Other welfare benefits provided | PFL | Welfare Benefit Premiums Paid to Carrier | USD $156,655 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $6,376 | Insurance broker organization code? | 3 |
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EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 ) |
Policy contract number | 041537/500380 |
Policy instance | 2 |
Insurance contract or identification number | 041537/500380 | Number of Individuals Covered | 257 | Insurance policy start date | 2021-01-01 | Insurance policy end date | 2021-12-31 | Total amount of commissions paid to insurance broker | USD $70,862 | Total amount of fees paid to insurance company | USD $0 | Health Insurance Welfare Benefit | Yes | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $70,862 | Insurance broker organization code? | 3 |
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FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 ) |
Policy contract number | 96676 |
Policy instance | 3 |
Insurance contract or identification number | 96676 | Number of Individuals Covered | 373 | Insurance policy start date | 2019-06-01 | Insurance policy end date | 2020-05-31 | Total amount of commissions paid to insurance broker | USD $8,316 | Total amount of fees paid to insurance company | USD $0 | Life Insurance Welfare Benefit | Yes | Long Term Disability Insurance Welfare Benefit | Yes | Other welfare benefits provided | AD&D | Welfare Benefit Premiums Paid to Carrier | USD $136,621 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $8,316 | Insurance broker organization code? | 3 |
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FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 ) |
Policy contract number | 96676 |
Policy instance | 5 |
Insurance contract or identification number | 96676 | Number of Individuals Covered | 373 | Insurance policy start date | 2020-06-01 | Insurance policy end date | 2020-12-31 | Total amount of commissions paid to insurance broker | USD $7,328 | Total amount of fees paid to insurance company | USD $0 | Life Insurance Welfare Benefit | Yes | Long Term Disability Insurance Welfare Benefit | Yes | Other welfare benefits provided | AD&D | Welfare Benefit Premiums Paid to Carrier | USD $81,263 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $7,328 | Insurance broker organization code? | 3 |
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EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 ) |
Policy contract number | 041537/500380 |
Policy instance | 2 |
Insurance contract or identification number | 041537/500380 | Number of Individuals Covered | 248 | Insurance policy start date | 2020-01-01 | Insurance policy end date | 2020-12-31 | Total amount of commissions paid to insurance broker | USD $68,205 | Total amount of fees paid to insurance company | USD $0 | Health Insurance Welfare Benefit | Yes | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $68,205 | Insurance broker organization code? | 3 |
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FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 ) |
Policy contract number | 407242 |
Policy instance | 6 |
Insurance contract or identification number | 407242 | Number of Individuals Covered | 41 | Insurance policy start date | 2020-06-01 | Insurance policy end date | 2020-12-31 | Total amount of commissions paid to insurance broker | USD $2,160 | Total amount of fees paid to insurance company | USD $0 | Life Insurance Welfare Benefit | Yes | Other welfare benefits provided | AD&D | Welfare Benefit Premiums Paid to Carrier | USD $14,397 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $2,160 | Insurance broker organization code? | 3 |
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VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 47029 ) |
Policy contract number | 30032039 |
Policy instance | 1 |
Insurance contract or identification number | 30032039 | Number of Individuals Covered | 167 | Insurance policy start date | 2020-01-01 | Insurance policy end date | 2020-12-31 | Total amount of commissions paid to insurance broker | USD $1,405 | Total amount of fees paid to insurance company | USD $0 | Vision Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $29,953 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $1,405 | Insurance broker organization code? | 3 |
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FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 ) |
Policy contract number | 407242 |
Policy instance | 4 |
Insurance contract or identification number | 407242 | Number of Individuals Covered | 32 | Insurance policy start date | 2019-06-01 | Insurance policy end date | 2020-05-31 | Total amount of commissions paid to insurance broker | USD $2,626 | Total amount of fees paid to insurance company | USD $0 | Life Insurance Welfare Benefit | Yes | Other welfare benefits provided | AD&D | Welfare Benefit Premiums Paid to Carrier | USD $17,509 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $2,626 | Insurance broker organization code? | 3 |
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EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 ) |
Policy contract number | 041537/500380 |
Policy instance | 2 |
Insurance contract or identification number | 041537/500380 | Number of Individuals Covered | 187 | Insurance policy start date | 2019-01-01 | Insurance policy end date | 2019-12-31 | Total amount of commissions paid to insurance broker | USD $62,437 | Total amount of fees paid to insurance company | USD $0 | Health Insurance Welfare Benefit | Yes | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $62,437 | Insurance broker organization code? | 3 |
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VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 47029 ) |
Policy contract number | 30032039 |
Policy instance | 1 |
Insurance contract or identification number | 30032039 | Number of Individuals Covered | 121 | Insurance policy start date | 2019-01-01 | Insurance policy end date | 2019-12-31 | Total amount of commissions paid to insurance broker | USD $1,237 | Total amount of fees paid to insurance company | USD $0 | Vision Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $23,955 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $1,237 | Insurance broker organization code? | 3 |
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FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 ) |
Policy contract number | 407242 |
Policy instance | 4 |
Insurance contract or identification number | 407242 | Number of Individuals Covered | 30 | Insurance policy start date | 2018-06-01 | Insurance policy end date | 2019-05-31 | Total amount of commissions paid to insurance broker | USD $2,656 | Total amount of fees paid to insurance company | USD $0 | Life Insurance Welfare Benefit | Yes | Other welfare benefits provided | AD&D | Welfare Benefit Premiums Paid to Carrier | USD $16,206 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $2,656 | Insurance broker organization code? | 3 |
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FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 ) |
Policy contract number | 96676 |
Policy instance | 3 |
Insurance contract or identification number | 96676 | Number of Individuals Covered | 318 | Insurance policy start date | 2018-06-01 | Insurance policy end date | 2019-05-31 | Total amount of commissions paid to insurance broker | USD $8,144 | Total amount of fees paid to insurance company | USD $0 | Life Insurance Welfare Benefit | Yes | Long Term Disability Insurance Welfare Benefit | Yes | Other welfare benefits provided | AD&D | Welfare Benefit Premiums Paid to Carrier | USD $115,592 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $8,144 | Insurance broker organization code? | 3 |
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VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 47029 ) |
Policy contract number | 30032039 |
Policy instance | 1 |
Insurance contract or identification number | 30032039 | Number of Individuals Covered | 125 | Insurance policy start date | 2018-01-01 | Insurance policy end date | 2018-12-31 | Total amount of commissions paid to insurance broker | USD $1,126 | Total amount of fees paid to insurance company | USD $0 | Vision Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $22,023 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $1,126 | Insurance broker organization code? | 3 |
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EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 ) |
Policy contract number | 041537/500380 |
Policy instance | 2 |
Insurance contract or identification number | 041537/500380 | Number of Individuals Covered | 184 | Insurance policy start date | 2018-01-01 | Insurance policy end date | 2018-12-31 | Total amount of commissions paid to insurance broker | USD $57,529 | Total amount of fees paid to insurance company | USD $0 | Health Insurance Welfare Benefit | Yes | Other welfare benefits provided | MEDICARE RISK | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $57,529 | Insurance broker organization code? | 3 |
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FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 ) |
Policy contract number | 96676004 |
Policy instance | 5 |
Insurance contract or identification number | 96676004 | Number of Individuals Covered | 55 | Insurance policy start date | 2017-06-01 | Insurance policy end date | 2018-05-31 | Total amount of commissions paid to insurance broker | USD $820 | Total amount of fees paid to insurance company | USD $0 | Life Insurance Welfare Benefit | Yes | Long Term Disability Insurance Welfare Benefit | Yes | Other welfare benefits provided | AD&D | Welfare Benefit Premiums Paid to Carrier | USD $18,230 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $820 | Insurance broker organization code? | 3 |
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FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 ) |
Policy contract number | 96676001 |
Policy instance | 3 |
Insurance contract or identification number | 96676001 | Number of Individuals Covered | 229 | Insurance policy start date | 2017-06-01 | Insurance policy end date | 2018-05-31 | Total amount of commissions paid to insurance broker | USD $4,746 | Total amount of fees paid to insurance company | USD $0 | Life Insurance Welfare Benefit | Yes | Long Term Disability Insurance Welfare Benefit | Yes | Other welfare benefits provided | AD&D | Welfare Benefit Premiums Paid to Carrier | USD $78,209 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $4,746 | Insurance broker organization code? | 3 |
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FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 ) |
Policy contract number | 407242 |
Policy instance | 4 |
Insurance contract or identification number | 407242 | Number of Individuals Covered | 29 | Insurance policy start date | 2017-06-01 | Insurance policy end date | 2018-05-31 | Total amount of commissions paid to insurance broker | USD $2,197 | Total amount of fees paid to insurance company | USD $0 | Life Insurance Welfare Benefit | Yes | Long Term Disability Insurance Welfare Benefit | Yes | Other welfare benefits provided | AD&D | Welfare Benefit Premiums Paid to Carrier | USD $14,921 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $2,197 | Insurance broker organization code? | 3 |
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FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 ) |
Policy contract number | 407242 |
Policy instance | 4 |
Insurance contract or identification number | 407242 | Number of Individuals Covered | 26 | Insurance policy start date | 2016-06-01 | Insurance policy end date | 2017-05-31 | Total amount of commissions paid to insurance broker | USD $1,615 | Total amount of fees paid to insurance company | USD $0 | Life Insurance Welfare Benefit | Yes | Other welfare benefits provided | AD&D | Welfare Benefit Premiums Paid to Carrier | USD $11,994 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $1,615 | Insurance broker organization code? | 3 | Insurance broker name | THE EVANS AGENCY LLC |
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FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 ) |
Policy contract number | 096676 |
Policy instance | 3 |
Insurance contract or identification number | 096676 | Number of Individuals Covered | 262 | Insurance policy start date | 2016-06-01 | Insurance policy end date | 2017-05-31 | Total amount of commissions paid to insurance broker | USD $7,865 | Total amount of fees paid to insurance company | USD $0 | Life Insurance Welfare Benefit | Yes | Long Term Disability Insurance Welfare Benefit | Yes | Other welfare benefits provided | AD&D | Welfare Benefit Premiums Paid to Carrier | USD $100,467 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $7,865 | Insurance broker organization code? | 3 | Insurance broker name | THE EVANS AGENCY LLC |
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EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 ) |
Policy contract number | 041537/500380 |
Policy instance | 2 |
Insurance contract or identification number | 041537/500380 | Number of Individuals Covered | 162 | Insurance policy start date | 2017-01-01 | Insurance policy end date | 2017-12-31 | Total amount of commissions paid to insurance broker | USD $52,268 | Total amount of fees paid to insurance company | USD $0 | Health Insurance Welfare Benefit | Yes | Other welfare benefits provided | MEDICARE RISK | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $28,005 | Insurance broker organization code? | 3 | Insurance broker name | THE EVANS AGENCY LLC |
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VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 47029 ) |
Policy contract number | 30032039 |
Policy instance | 1 |
Insurance contract or identification number | 30032039 | Number of Individuals Covered | 108 | Insurance policy start date | 2017-01-01 | Insurance policy end date | 2017-12-31 | Total amount of commissions paid to insurance broker | USD $1,120 | Total amount of fees paid to insurance company | USD $0 | Vision Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $18,827 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $954 | Insurance broker organization code? | 3 | Insurance broker name | THE EVANS AGENCY LLC |
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FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 ) |
Policy contract number | 407242 |
Policy instance | 4 |
Insurance contract or identification number | 407242 | Number of Individuals Covered | 23 | Insurance policy start date | 2015-01-01 | Insurance policy end date | 2015-05-31 | Total amount of commissions paid to insurance broker | USD $473 | Total amount of fees paid to insurance company | USD $0 | Life Insurance Welfare Benefit | Yes | Other welfare benefits provided | AD&D | Welfare Benefit Premiums Paid to Carrier | USD $1,154 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $473 | Insurance broker organization code? | 3 | Insurance broker name | THE EVANS AGENCY LLC |
|
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 47029 ) |
Policy contract number | 30032039 |
Policy instance | 1 |
Insurance contract or identification number | 30032039 | Number of Individuals Covered | 104 | Insurance policy start date | 2015-01-01 | Insurance policy end date | 2015-12-31 | Total amount of commissions paid to insurance broker | USD $994 | Total amount of fees paid to insurance company | USD $0 | Vision Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $16,858 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $994 | Insurance broker organization code? | 3 | Insurance broker name | MERCER HEALTH & BENEFITS, LLC |
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EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 ) |
Policy contract number | 041537/500380 |
Policy instance | 2 |
Insurance contract or identification number | 041537/500380 | Number of Individuals Covered | 149 | Insurance policy start date | 2015-01-01 | Insurance policy end date | 2015-12-31 | Total amount of commissions paid to insurance broker | USD $44,726 | Total amount of fees paid to insurance company | USD $0 | Health Insurance Welfare Benefit | Yes | Other welfare benefits provided | MEDICARE RISK | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $44,726 | Insurance broker organization code? | 3 | Insurance broker name | MERCER HEALTH & BENEFITS, LLC |
|
FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 ) |
Policy contract number | 096676 |
Policy instance | 3 |
Insurance contract or identification number | 096676 | Number of Individuals Covered | 256 | Insurance policy start date | 2014-06-01 | Insurance policy end date | 2015-05-31 | Total amount of commissions paid to insurance broker | USD $6,431 | Total amount of fees paid to insurance company | USD $0 | Life Insurance Welfare Benefit | Yes | Long Term Disability Insurance Welfare Benefit | Yes | Other welfare benefits provided | AD&D | Welfare Benefit Premiums Paid to Carrier | USD $69,623 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $6,431 | Insurance broker organization code? | 3 | Insurance broker name | THE EVANS AGENCY LLC |
|
FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 ) |
Policy contract number | 096676 |
Policy instance | 3 |
Insurance contract or identification number | 096676 | Number of Individuals Covered | 256 | Insurance policy start date | 2013-06-01 | Insurance policy end date | 2014-05-31 | Total amount of commissions paid to insurance broker | USD $6,376 | Total amount of fees paid to insurance company | USD $635 | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Life Insurance Welfare Benefit | Yes | Long Term Disability Insurance Welfare Benefit | Yes | Other welfare benefits provided | AD&D | Welfare Benefit Premiums Paid to Carrier | USD $68,513 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $5,444 | Amount paid for insurance broker fees | 635 | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION PAID | Insurance broker organization code? | 3 | Insurance broker name | THE EVANS AGENCY LLC |
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EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 ) |
Policy contract number | 041537/500380 |
Policy instance | 2 |
Insurance contract or identification number | 041537/500380 | Number of Individuals Covered | 151 | Insurance policy start date | 2014-01-01 | Insurance policy end date | 2014-12-31 | Total amount of commissions paid to insurance broker | USD $42,264 | Total amount of fees paid to insurance company | USD $0 | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Health Insurance Welfare Benefit | Yes | Other welfare benefits provided | MEDICARE RISK | Welfare Benefit Premiums Paid to Carrier | USD $12,221 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $42,264 | Insurance broker organization code? | 3 | Insurance broker name | MERCER HEALTH & BENEFITS, LLC |
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VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 47029 ) |
Policy contract number | 30032039 |
Policy instance | 1 |
Insurance contract or identification number | 30032039 | Number of Individuals Covered | 95 | Insurance policy start date | 2014-01-01 | Insurance policy end date | 2014-12-31 | Total amount of commissions paid to insurance broker | USD $941 | Total amount of fees paid to insurance company | USD $0 | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Vision Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $15,373 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $941 | Insurance broker organization code? | 3 | Insurance broker name | MERCER HEALTH & BENEFITS, LLC |
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FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 ) |
Policy contract number | 096676 |
Policy instance | 3 |
Insurance contract or identification number | 096676 | Number of Individuals Covered | 241 | Insurance policy start date | 2012-06-01 | Insurance policy end date | 2013-05-31 | Total amount of commissions paid to insurance broker | USD $6,183 | Total amount of fees paid to insurance company | USD $622 | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Life Insurance Welfare Benefit | Yes | Long Term Disability Insurance Welfare Benefit | Yes | Other welfare benefits provided | AD&D | Welfare Benefit Premiums Paid to Carrier | USD $64,655 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $6,183 | Amount paid for insurance broker fees | 622 | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION PAID | Insurance broker organization code? | 3 | Insurance broker name | KAFL, INC. |
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EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 ) |
Policy contract number | 041537/500380 |
Policy instance | 2 |
Insurance contract or identification number | 041537/500380 | Number of Individuals Covered | 150 | Insurance policy start date | 2013-01-01 | Insurance policy end date | 2013-12-31 | Total amount of commissions paid to insurance broker | USD $36,537 | Total amount of fees paid to insurance company | USD $0 | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Health Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $8,495 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $36,432 | Insurance broker organization code? | 3 | Insurance broker name | LIAZON BENEFITS, INC. |
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VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 47029 ) |
Policy contract number | 30032039 |
Policy instance | 1 |
Insurance contract or identification number | 30032039 | Number of Individuals Covered | 85 | Insurance policy start date | 2013-01-01 | Insurance policy end date | 2013-12-31 | Total amount of commissions paid to insurance broker | USD $856 | Total amount of fees paid to insurance company | USD $0 | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Vision Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $12,429 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $856 | Insurance broker organization code? | 3 | Insurance broker name | MERCER HEALTH & BENEFITS, LLC |
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EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 ) |
Policy contract number | 00041537 |
Policy instance | 2 |
Insurance contract or identification number | 00041537 | Number of Individuals Covered | 143 | Insurance policy start date | 2011-03-01 | Insurance policy end date | 2012-02-28 | Total amount of commissions paid to insurance broker | USD $44,156 | Total amount of fees paid to insurance company | USD $0 | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Health Insurance Welfare Benefit | Yes | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $44,156 | Insurance broker organization code? | 3 | Insurance broker name | LIAZON BENEFITS, INC. |
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EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 ) |
Policy contract number | 00041537 |
Policy instance | 4 |
Insurance contract or identification number | 00041537 | Number of Individuals Covered | 145 | Insurance policy start date | 2012-03-01 | Insurance policy end date | 2012-12-31 | Total amount of commissions paid to insurance broker | USD $45,464 | Total amount of fees paid to insurance company | USD $0 | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Health Insurance Welfare Benefit | Yes | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $45,464 | Insurance broker name | LIAZON BENEFITS, INC. |
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FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 ) |
Policy contract number | 096676 |
Policy instance | 3 |
Insurance contract or identification number | 096676 | Number of Individuals Covered | 236 | Insurance policy start date | 2011-06-01 | Insurance policy end date | 2012-05-31 | Total amount of commissions paid to insurance broker | USD $6,817 | Total amount of fees paid to insurance company | USD $0 | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Life Insurance Welfare Benefit | Yes | Long Term Disability Insurance Welfare Benefit | Yes | Other welfare benefits provided | AD&D | Welfare Benefit Premiums Paid to Carrier | USD $61,348 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $6,817 | Insurance broker organization code? | 3 | Insurance broker name | KAFL, INC. |
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VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 47029 ) |
Policy contract number | 30032039 |
Policy instance | 1 |
Insurance contract or identification number | 30032039 | Number of Individuals Covered | 73 | Insurance policy start date | 2012-03-01 | Insurance policy end date | 2012-12-31 | Total amount of commissions paid to insurance broker | USD $681 | Total amount of fees paid to insurance company | USD $0 | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Vision Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $8,626 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $497 | Insurance broker organization code? | 3 | Insurance broker name | MERCER HEALTH & BENEFITS, LLC |
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EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 ) |
Policy contract number | 041537, 701409 |
Policy instance | 1 |
Insurance contract or identification number | 041537, 701409 | Number of Individuals Covered | 144 | Insurance policy start date | 2010-03-01 | Insurance policy end date | 2011-02-28 | Total amount of commissions paid to insurance broker | USD $42,283 | Total amount of fees paid to insurance company | USD $0 | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Health Insurance Welfare Benefit | Yes | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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SUN LIFE INSURANCE AND ANNUITY COMPANY OF NEW YORK (National Association of Insurance Commissioners NAIC id number: 80926 ) |
Policy contract number | 063136 |
Policy instance | 2 |
Insurance contract or identification number | 063136 | Number of Individuals Covered | 229 | Insurance policy start date | 2010-03-01 | Insurance policy end date | 2011-02-28 | Total amount of commissions paid to insurance broker | USD $8,428 | Total amount of fees paid to insurance company | USD $0 | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Life Insurance Welfare Benefit | Yes | Long Term Disability Insurance Welfare Benefit | Yes | Other welfare benefits provided | AD&D | Welfare Benefit Premiums Paid to Carrier | USD $53,391 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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SUN LIFE INSURANCE AND ANNUITY COMPANY OF NEW YORK (National Association of Insurance Commissioners NAIC id number: 80926 ) |
Policy contract number | 063136 |
Policy instance | 3 |
Insurance contract or identification number | 063136 | Number of Individuals Covered | 0 | Insurance policy start date | 2011-03-01 | Insurance policy end date | 2011-05-31 | Total amount of commissions paid to insurance broker | USD $2,391 | Total amount of fees paid to insurance company | USD $0 | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | Life Insurance Welfare Benefit | Yes | Long Term Disability Insurance Welfare Benefit | Yes | Other welfare benefits provided | AD&D | Welfare Benefit Premiums Paid to Carrier | USD $20,505 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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SUN LIFE INSURANCE AND ANNUITY COMPANY OF NEW YORK (National Association of Insurance Commissioners NAIC id number: 80926 ) |
Policy contract number | 063136 |
Policy instance | 1 |
Insurance contract or identification number | 063136 | Number of Individuals Covered | 218 | Insurance policy start date | 2009-03-01 | Insurance policy end date | 2010-02-28 | Total amount of commissions paid to insurance broker | USD $7,898 | Total amount of fees paid to insurance company | USD $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 plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | 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 Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | Yes | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | AD&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 Carrier | USD $46,427 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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INDEPENDENT HEALTH (National Association of Insurance Commissioners NAIC id number: 47034 ) |
Policy contract number | B3670K |
Policy instance | 2 |
Insurance contract or identification number | B3670K | Number of Individuals Covered | 0 | Insurance policy start date | 2010-01-01 | Insurance policy end date | 2010-12-31 | Total amount of commissions paid to insurance broker | USD $3,873 | Total amount of fees paid to insurance company | USD $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 plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | 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 Benefit | Yes | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | 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 Carrier | USD $64,050 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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INDEPENDENT HEALTH (National Association of Insurance Commissioners NAIC id number: 47034 ) |
Policy contract number | C0040K |
Policy instance | 3 |
Insurance contract or identification number | C0040K | Number of Individuals Covered | 0 | Insurance policy start date | 2010-01-01 | Insurance policy end date | 2010-12-31 | 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 plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | 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 Benefit | Yes | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | 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 Carrier | USD $4,093 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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HARTFORD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 88072 ) |
Policy contract number | 855704G |
Policy instance | 4 |
Insurance contract or identification number | 855704G | Number of Individuals Covered | 0 | Insurance policy start date | 2009-03-01 | Insurance policy end date | 2010-02-28 | 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 plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | 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 Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | Yes | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | AD&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 Carrier | USD $1,454 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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INDEPENDENT HEALTH (National Association of Insurance Commissioners NAIC id number: 47034 ) |
Policy contract number | B3670R |
Policy instance | 5 |
Insurance contract or identification number | B3670R | Number of Individuals Covered | 0 | Insurance policy start date | 2010-01-01 | Insurance policy end date | 2010-12-31 | 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 plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | 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 Benefit | Yes | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | 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 Carrier | USD $18,046 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
INDEPENDENT HEALTH (National Association of Insurance Commissioners NAIC id number: 47034 ) |
Policy contract number | B3670Q |
Policy instance | 6 |
Insurance contract or identification number | B3670Q | Number of Individuals Covered | 0 | Insurance policy start date | 2010-01-01 | Insurance policy end date | 2010-12-31 | 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 plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | 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 Benefit | Yes | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | 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 Carrier | USD $19,343 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 ) |
Policy contract number | 041537, 701409 |
Policy instance | 7 |
Insurance contract or identification number | 041537, 701409 | Number of Individuals Covered | 233 | Insurance policy start date | 2010-01-01 | Insurance policy end date | 2010-12-31 | Total amount of commissions paid to insurance broker | USD $34,656 | Total amount of fees paid to insurance company | USD $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 plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | 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 Benefit | Yes | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | 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 |
|
INDEPENDENT HEALTH (National Association of Insurance Commissioners NAIC id number: 47034 ) |
Policy contract number | C0040Q |
Policy instance | 8 |
Insurance contract or identification number | C0040Q | Number of Individuals Covered | 0 | Insurance policy start date | 2010-01-01 | Insurance policy end date | 2010-12-31 | 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 plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | 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 Benefit | Yes | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | 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 Carrier | USD $234 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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INDEPENDENT HEALTH (National Association of Insurance Commissioners NAIC id number: 47034 ) |
Policy contract number | B3670R |
Policy instance | 1 |
Insurance contract or identification number | B3670R | Number of Individuals Covered | 33 | Insurance policy start date | 2008-01-01 | Insurance policy end date | 2008-12-31 | 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 plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | 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 Benefit | Yes | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | 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 Carrier | USD $60,898 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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INDEPENDENT HEALTH (National Association of Insurance Commissioners NAIC id number: 47034 ) |
Policy contract number | B3670Q |
Policy instance | 2 |
Insurance contract or identification number | B3670Q | Number of Individuals Covered | 67 | Insurance policy start date | 2008-01-01 | Insurance policy end date | 2008-12-31 | 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 plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | 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 Benefit | Yes | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | 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 Carrier | USD $91,159 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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INDEPENDENT HEALTH (National Association of Insurance Commissioners NAIC id number: 47034 ) |
Policy contract number | B3670G |
Policy instance | 3 |
Insurance contract or identification number | B3670G | Number of Individuals Covered | 92 | Insurance policy start date | 2008-01-01 | Insurance policy end date | 2008-12-31 | 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 plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | 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 Benefit | Yes | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | 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 Carrier | USD $273,457 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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HARTFORD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 88072 ) |
Policy contract number | 855704G |
Policy instance | 4 |
Insurance contract or identification number | 855704G | Number of Individuals Covered | 193 | Insurance policy start date | 2007-03-01 | Insurance policy end date | 2008-02-28 | Total amount of commissions paid to insurance broker | USD $5,372 | Total amount of fees paid to insurance company | USD $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 plan | No | Contracts With Unallocated Funds Deposit Administration | 0 | 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 Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | Yes | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | AD&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 Carrier | USD $42,526 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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