BUFFALO MEDICAL GROUP, P.C. has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan BUFFALO MEDICAL GROUP PC WELFARE PLAN
| HARTFORD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 88072 ) |
| Policy contract number | ADD-S06846 |
| Policy instance | 9 |
| Insurance contract or identification number | ADD-S06846 | | Number of Individuals Covered | 222 | | Insurance policy start date | 2021-07-01 | | Insurance policy end date | 2022-06-30 | | Total amount of commissions paid to insurance broker | USD $685 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $6,848 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $685 | | Insurance broker organization code? | 3 |
|
| INDEPENDENT HEALTH (National Association of Insurance Commissioners NAIC id number: 95308 ) |
| Policy contract number | 13877 |
| Policy instance | 6 |
| Insurance contract or identification number | 13877 | | Number of Individuals Covered | 4 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $20,751 | | 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 | 00130576 |
| Policy instance | 7 |
| Insurance contract or identification number | 00130576 | | Number of Individuals Covered | 472 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | 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 |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 926155 |
| Policy instance | 8 |
| Insurance contract or identification number | 926155 | | Number of Individuals Covered | 633 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $23,364 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Insurance broker organization code? | 3 |
|
| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
| Policy contract number | 038380G/460698G |
| Policy instance | 1 |
| Insurance contract or identification number | 038380G/460698G | | Number of Individuals Covered | 359 | | Insurance policy start date | 2022-07-01 | | Insurance policy end date | 2023-06-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $15,515 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | CRITICAL ILLNESS | | Welfare Benefit Premiums Paid to Carrier | USD $438,552 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 15515 | | Additional information about fees paid to insurance broker | BONUS PAID | | Insurance broker organization code? | 3 |
|
| THE PAUL REVERE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 67598 ) |
| Policy contract number | 0007372621 |
| Policy instance | 2 |
| Insurance contract or identification number | 0007372621 | | Number of Individuals Covered | 2 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2023-01-01 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $725 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| PROVIDENT LIFE AND CASUALTY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68209 ) |
| Policy contract number | 008836 |
| Policy instance | 3 |
| Insurance contract or identification number | 008836 | | Number of Individuals Covered | 6 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2023-01-01 | | Total amount of commissions paid to insurance broker | USD $492 | | Total amount of fees paid to insurance company | USD $0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $4,763 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $143 | | Insurance broker organization code? | 3 |
|
| PROVIDENT LIFE AND CASUALTY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68209 ) |
| Policy contract number | 132878 |
| Policy instance | 4 |
| Insurance contract or identification number | 132878 | | Number of Individuals Covered | 54 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2023-01-01 | | Total amount of commissions paid to insurance broker | USD $2,578 | | Total amount of fees paid to insurance company | USD $0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $86,653 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,414 | | Insurance broker organization code? | 3 |
|
| PROVIDENT LIFE AND CASUALTY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68209 ) |
| Policy contract number | 155615 |
| Policy instance | 5 |
| Insurance contract or identification number | 155615 | | Number of Individuals Covered | 64 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2023-01-01 | | Total amount of commissions paid to insurance broker | USD $7,869 | | Total amount of fees paid to insurance company | USD $0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $110,765 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,053 | | Insurance broker organization code? | 3 |
|
| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
| Policy contract number | 038380G |
| Policy instance | 1 |
| Insurance contract or identification number | 038380G | | Number of Individuals Covered | 320 | | Insurance policy start date | 2020-07-01 | | Insurance policy end date | 2021-06-30 | | Total amount of commissions paid to insurance broker | USD $13,431 | | Total amount of fees paid to insurance company | USD $640 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $236,786 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $13,438 | | Amount paid for insurance broker fees | 640 | | Additional information about fees paid to insurance broker | BONUS PAID | | Insurance broker organization code? | 3 |
|
| THE PAUL REVERE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 67598 ) |
| Policy contract number | 0007372621 |
| Policy instance | 2 |
| Insurance contract or identification number | 0007372621 | | Number of Individuals Covered | 4 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2022-01-01 | | Total amount of commissions paid to insurance broker | USD $2 | | Total amount of fees paid to insurance company | USD $0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,123 | | 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 | | Insurance broker organization code? | 3 |
|
| PROVIDENT LIFE AND CASUALTY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68209 ) |
| Policy contract number | 008836 |
| Policy instance | 3 |
| Insurance contract or identification number | 008836 | | Number of Individuals Covered | 6 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2022-01-01 | | Total amount of commissions paid to insurance broker | USD $380 | | Total amount of fees paid to insurance company | USD $0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $5,160 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $103 | | Insurance broker organization code? | 3 |
|
| PROVIDENT LIFE AND CASUALTY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68209 ) |
| Policy contract number | 132878 |
| Policy instance | 4 |
| Insurance contract or identification number | 132878 | | Number of Individuals Covered | 59 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2022-01-01 | | Total amount of commissions paid to insurance broker | USD $2,972 | | Total amount of fees paid to insurance company | USD $0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $98,015 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,701 | | Insurance broker organization code? | 3 |
|
| LINCOLN LIFE AND ANNUITY CO OF NY (National Association of Insurance Commissioners NAIC id number: 62057 ) |
| Policy contract number | 000010183111 |
| Policy instance | 5 |
| Insurance contract or identification number | 000010183111 | | Number of Individuals Covered | 233 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $23,602 | | Total amount of fees paid to insurance company | USD $2,368 | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $157,343 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $11,840 | | Amount paid for insurance broker fees | 2368 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker organization code? | 3 |
|
| LINCOLN LIFE AND ANNUITY CO OF NY (National Association of Insurance Commissioners NAIC id number: 62057 ) |
| Policy contract number | 000010183110 |
| Policy instance | 6 |
| Insurance contract or identification number | 000010183110 | | Number of Individuals Covered | 189 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $9,886 | | Total amount of fees paid to insurance company | USD $976 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $65,905 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,880 | | Amount paid for insurance broker fees | 976 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker organization code? | 3 |
|
| LINCOLN LIFE AND ANNUITY CO OF NY (National Association of Insurance Commissioners NAIC id number: 62057 ) |
| Policy contract number | 000010230477 |
| Policy instance | 9 |
| Insurance contract or identification number | 000010230477 | | Number of Individuals Covered | 955 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Temporary Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | NY FAMILY LEAVE | | Welfare Benefit Premiums Paid to Carrier | USD $335,427 | | 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: 95308 ) |
| Policy contract number | 13877 |
| Policy instance | 8 |
| Insurance contract or identification number | 13877 | | Number of Individuals Covered | 4 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $23,463 | | 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 | 00130576 |
| Policy instance | 10 |
| Insurance contract or identification number | 00130576 | | Number of Individuals Covered | 463 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | 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 |
|
| PROVIDENT LIFE AND CASUALTY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68209 ) |
| Policy contract number | 155615 |
| Policy instance | 7 |
| Insurance contract or identification number | 155615 | | Number of Individuals Covered | 70 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2022-01-01 | | Total amount of commissions paid to insurance broker | USD $10,238 | | Total amount of fees paid to insurance company | USD $0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $106,885 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,740 | | Insurance broker organization code? | 3 |
|
| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
| Policy contract number | ADDS06846 |
| Policy instance | 5 |
| Insurance contract or identification number | ADDS06846 | | Number of Individuals Covered | 189 | | Insurance policy start date | 2019-07-01 | | Insurance policy end date | 2020-06-30 | | Total amount of commissions paid to insurance broker | USD $540 | | Total amount of fees paid to insurance company | USD $12 | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $5,397 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $540 | | Amount paid for insurance broker fees | 12 | | Additional information about fees paid to insurance broker | BONUS | | Insurance broker organization code? | 4 |
|
| PROVIDENT LIFE AND CASUALTY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68209 ) |
| Policy contract number | 008836 |
| Policy instance | 3 |
| Insurance contract or identification number | 008836 | | Number of Individuals Covered | 6 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2021-01-01 | | Total amount of commissions paid to insurance broker | USD $410 | | Total amount of fees paid to insurance company | USD $0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $3,969 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $119 | | Insurance broker organization code? | 3 |
|
| THE PAUL REVERE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 67598 ) |
| Policy contract number | 0007372621 |
| Policy instance | 2 |
| Insurance contract or identification number | 0007372621 | | Number of Individuals Covered | 34 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2021-01-01 | | Total amount of commissions paid to insurance broker | USD $715 | | Total amount of fees paid to insurance company | USD $0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $14,825 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $282 | | Insurance broker organization code? | 3 |
|
| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
| Policy contract number | 038380G |
| Policy instance | 1 |
| Insurance contract or identification number | 038380G | | Number of Individuals Covered | 233 | | Insurance policy start date | 2019-07-01 | | Insurance policy end date | 2020-06-30 | | Total amount of commissions paid to insurance broker | USD $16,830 | | Total amount of fees paid to insurance company | USD $453 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $176,342 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $10,865 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 453 | | Additional information about fees paid to insurance broker | BONUS |
|
| INDEPENDENT HEALTH (National Association of Insurance Commissioners NAIC id number: 47034 ) |
| Policy contract number | 18479 |
| Policy instance | 6 |
| Insurance contract or identification number | 18479 | | Number of Individuals Covered | 465 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | 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 |
|
| LINCOLN LIFE AND ANNUITY CO OF NY (National Association of Insurance Commissioners NAIC id number: 62057 ) |
| Policy contract number | 000010183111 |
| Policy instance | 7 |
| Insurance contract or identification number | 000010183111 | | Number of Individuals Covered | 200 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $22,939 | | Total amount of fees paid to insurance company | USD $4,588 | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $152,927 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $22,939 | | Amount paid for insurance broker fees | 4588 | | Additional information about fees paid to insurance broker | ADDITIONAL FEES | | Insurance broker organization code? | 3 |
|
| PROVIDENT LIFE AND CASUALTY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68209 ) |
| Policy contract number | 132878 |
| Policy instance | 4 |
| Insurance contract or identification number | 132878 | | Number of Individuals Covered | 61 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2021-01-01 | | Total amount of commissions paid to insurance broker | USD $2,581 | | Total amount of fees paid to insurance company | USD $0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $83,821 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,647 | | Insurance broker organization code? | 3 |
|
| LINCOLN LIFE AND ANNUITY CO OF NY (National Association of Insurance Commissioners NAIC id number: 62057 ) |
| Policy contract number | 000010230477 |
| Policy instance | 11 |
| Insurance contract or identification number | 000010230477 | | Number of Individuals Covered | 906 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Temporary Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | NY FAMILY LEAVE | | Welfare Benefit Premiums Paid to Carrier | USD $188,820 | | 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: 95308 ) |
| Policy contract number | 13877 |
| Policy instance | 10 |
| Insurance contract or identification number | 13877 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | 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 |
|
| PROVIDENT LIFE AND CASUALTY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68209 ) |
| Policy contract number | 155615 |
| Policy instance | 9 |
| Insurance contract or identification number | 155615 | | Number of Individuals Covered | 62 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2021-01-01 | | Total amount of commissions paid to insurance broker | USD $7,007 | | Total amount of fees paid to insurance company | USD $0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $80,172 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,475 | | Insurance broker organization code? | 3 |
|
| LINCOLN LIFE AND ANNUITY CO OF NY (National Association of Insurance Commissioners NAIC id number: 62057 ) |
| Policy contract number | 000010183110 |
| Policy instance | 8 |
| Insurance contract or identification number | 000010183110 | | Number of Individuals Covered | 149 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $9,310 | | Total amount of fees paid to insurance company | USD $1,862 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $62,065 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $9,310 | | Amount paid for insurance broker fees | 1862 | | Additional information about fees paid to insurance broker | ADDITIONAL FEES | | Insurance broker organization code? | 3 |
|
| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
| Policy contract number | 038380G |
| Policy instance | 1 |
| Insurance contract or identification number | 038380G | | Number of Individuals Covered | 192 | | Insurance policy start date | 2018-07-01 | | Insurance policy end date | 2019-06-30 | | Total amount of commissions paid to insurance broker | USD $17,895 | | Total amount of fees paid to insurance company | USD $475 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $135,157 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $11,562 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 475 | | Additional information about fees paid to insurance broker | BONUS |
|
| THE PAUL REVERE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 67598 ) |
| Policy contract number | 0007372621 |
| Policy instance | 2 |
| Insurance contract or identification number | 0007372621 | | Number of Individuals Covered | 35 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2020-01-01 | | Total amount of commissions paid to insurance broker | USD $785 | | Total amount of fees paid to insurance company | USD $0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $16,169 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $310 | | Insurance broker organization code? | 3 |
|
| PROVIDENT LIFE AND CASUALTY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68209 ) |
| Policy contract number | 008836 |
| Policy instance | 3 |
| Insurance contract or identification number | 008836 | | Number of Individuals Covered | 6 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2020-01-01 | | Total amount of commissions paid to insurance broker | USD $492 | | Total amount of fees paid to insurance company | USD $0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $4,763 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $143 | | Insurance broker organization code? | 3 |
|
| PROVIDENT LIFE AND CASUALTY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68209 ) |
| Policy contract number | 132878 |
| Policy instance | 4 |
| Insurance contract or identification number | 132878 | | Number of Individuals Covered | 61 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2020-01-01 | | Total amount of commissions paid to insurance broker | USD $4,748 | | Total amount of fees paid to insurance company | USD $0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $105,592 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,327 | | Insurance broker organization code? | 3 |
|
| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
| Policy contract number | ADDS06846 |
| Policy instance | 5 |
| Insurance contract or identification number | ADDS06846 | | Number of Individuals Covered | 133 | | Insurance policy start date | 2018-07-01 | | Insurance policy end date | 2019-06-30 | | Total amount of commissions paid to insurance broker | USD $419 | | Total amount of fees paid to insurance company | USD $11 | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $4,185 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $419 | | Amount paid for insurance broker fees | 11 | | Additional information about fees paid to insurance broker | BONUS | | Insurance broker organization code? | 4 |
|
| INDEPENDENT HEALTH (National Association of Insurance Commissioners NAIC id number: 47034 ) |
| Policy contract number | 18479 |
| Policy instance | 6 |
| Insurance contract or identification number | 18479 | | Number of Individuals Covered | 489 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | 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 |
|
| LINCOLN LIFE AND ANNUITY CO OF NY (National Association of Insurance Commissioners NAIC id number: 62057 ) |
| Policy contract number | 000010183111 |
| Policy instance | 7 |
| Insurance contract or identification number | 000010183111 | | Number of Individuals Covered | 183 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $18,935 | | Total amount of fees paid to insurance company | USD $3,787 | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $126,236 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $18,935 | | Amount paid for insurance broker fees | 3787 | | Additional information about fees paid to insurance broker | ADDITIONAL FEES | | Insurance broker organization code? | 3 |
|
| LINCOLN LIFE AND ANNUITY CO OF NY (National Association of Insurance Commissioners NAIC id number: 62057 ) |
| Policy contract number | 000010183110 |
| Policy instance | 8 |
| Insurance contract or identification number | 000010183110 | | Number of Individuals Covered | 134 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $8,000 | | Total amount of fees paid to insurance company | USD $1,600 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $53,334 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,000 | | Amount paid for insurance broker fees | 1600 | | Additional information about fees paid to insurance broker | ADDITIONAL FEES | | Insurance broker organization code? | 3 |
|
| PROVIDENT LIFE AND CASUALTY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68209 ) |
| Policy contract number | 155615 |
| Policy instance | 9 |
| Insurance contract or identification number | 155615 | | Number of Individuals Covered | 56 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2020-01-01 | | Total amount of commissions paid to insurance broker | USD $8,364 | | Total amount of fees paid to insurance company | USD $0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $90,994 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,896 | | Insurance broker organization code? | 3 |
|
| INDEPENDENT HEALTH (National Association of Insurance Commissioners NAIC id number: 95308 ) |
| Policy contract number | 13877 |
| Policy instance | 10 |
| Insurance contract or identification number | 13877 | | Number of Individuals Covered | 4 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $21,803 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| PROVIDENT LIFE AND CASUALTY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68209 ) |
| Policy contract number | 132878 |
| Policy instance | 4 |
| Insurance contract or identification number | 132878 | | Number of Individuals Covered | 62 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2019-01-01 | | Total amount of commissions paid to insurance broker | USD $5,808 | | Total amount of fees paid to insurance company | USD $873 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $106,616 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,200 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 873 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION AND BONUS PAID |
|
| PROVIDENT LIFE AND CASUALTY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68209 ) |
| Policy contract number | 008836 |
| Policy instance | 3 |
| Insurance contract or identification number | 008836 | | Number of Individuals Covered | 6 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2019-01-01 | | Total amount of commissions paid to insurance broker | USD $492 | | Total amount of fees paid to insurance company | USD $0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $4,763 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $143 | | Insurance broker organization code? | 3 |
|
| THE PAUL REVERE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 67598 ) |
| Policy contract number | 0007372621 |
| Policy instance | 2 |
| Insurance contract or identification number | 0007372621 | | Number of Individuals Covered | 37 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2019-01-01 | | Total amount of commissions paid to insurance broker | USD $802 | | Total amount of fees paid to insurance company | USD $0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $16,504 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $315 | | Insurance broker organization code? | 3 |
|
| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
| Policy contract number | 038380G |
| Policy instance | 1 |
| Insurance contract or identification number | 038380G | | Number of Individuals Covered | 198 | | Insurance policy start date | 2017-07-01 | | Insurance policy end date | 2018-06-30 | | Total amount of commissions paid to insurance broker | USD $17,113 | | 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 | ACCIDENTAL DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $151,051 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $11,066 | | Insurance broker organization code? | 3 |
|
| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
| Policy contract number | ADDS06846 |
| Policy instance | 5 |
| Insurance contract or identification number | ADDS06846 | | Number of Individuals Covered | 116 | | Insurance policy start date | 2017-07-01 | | Insurance policy end date | 2018-06-30 | | Total amount of commissions paid to insurance broker | USD $454 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $4,540 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $454 | | Insurance broker organization code? | 3 |
|
| INDEPENDENT HEALTH (National Association of Insurance Commissioners NAIC id number: 47034 ) |
| Policy contract number | 18479 |
| Policy instance | 6 |
| Insurance contract or identification number | 18479 | | Number of Individuals Covered | 958 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | 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 |
|
| LINCOLN LIFE AND ANNUITY CO OF NY (National Association of Insurance Commissioners NAIC id number: 62057 ) |
| Policy contract number | 000010183111 |
| Policy instance | 7 |
| Insurance contract or identification number | 000010183111 | | Number of Individuals Covered | 190 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $19,302 | | Total amount of fees paid to insurance company | USD $3,861 | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $128,684 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $9,184 | | Amount paid for insurance broker fees | 2921 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION AND 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 number | 000010183110 |
| Policy instance | 8 |
| Insurance contract or identification number | 000010183110 | | Number of Individuals Covered | 140 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $7,713 | | Total amount of fees paid to insurance company | USD $1,543 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $51,415 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,695 | | Amount paid for insurance broker fees | 1164 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION AND BROKER BONUS | | Insurance broker organization code? | 3 |
|
| PROVIDENT LIFE AND CASUALTY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68209 ) |
| Policy contract number | 155615 |
| Policy instance | 9 |
| Insurance contract or identification number | 155615 | | Number of Individuals Covered | 54 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2019-01-01 | | Total amount of commissions paid to insurance broker | USD $10,225 | | Total amount of fees paid to insurance company | USD $0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $84,506 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,787 | | Insurance broker organization code? | 3 |
|
| INDEPENDENT HEALTH (National Association of Insurance Commissioners NAIC id number: 95308 ) |
| Policy contract number | 18479 |
| Policy instance | 10 |
| Insurance contract or identification number | 18479 | | Number of Individuals Covered | 15 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | 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 |
|
| INDEPENDENT HEALTH (National Association of Insurance Commissioners NAIC id number: 95308 ) |
| Policy contract number | 18479 |
| Policy instance | 10 |
| Insurance contract or identification number | 18479 | | Number of Individuals Covered | 15 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | 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 |
|
| PROVIDENT LIFE AND CASUALTY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68209 ) |
| Policy contract number | 155615 |
| Policy instance | 9 |
| Insurance contract or identification number | 155615 | | Number of Individuals Covered | 53 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2018-01-01 | | Total amount of commissions paid to insurance broker | USD $12,064 | | Total amount of fees paid to insurance company | USD $1,958 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $74,954 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,900 | | Amount paid for insurance broker fees | 1958 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION PAID | | Insurance broker organization code? | 3 | | Insurance broker name | ROBERT F FAHEY |
|
| LINCOLN LIFE AND ANNUITY CO OF NY (National Association of Insurance Commissioners NAIC id number: 62057 ) |
| Policy contract number | 000010183110 |
| Policy instance | 8 |
| Insurance contract or identification number | 000010183110 | | Number of Individuals Covered | 115 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $6,598 | | Total amount of fees paid to insurance company | USD $1,742 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $43,985 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,355 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 1742 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION AND BROKER BONUS | | Insurance broker name | BOND FINANCIAL NETWORK INC |
|
| LINCOLN LIFE AND ANNUITY CO OF NY (National Association of Insurance Commissioners NAIC id number: 62057 ) |
| Policy contract number | 000010183111 |
| Policy instance | 7 |
| Insurance contract or identification number | 000010183111 | | Number of Individuals Covered | 184 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $18,647 | | Total amount of fees paid to insurance company | USD $4,877 | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $124,318 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $12,307 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 4877 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION AND BROKER BONUS | | Insurance broker name | BOND FINANCIAL NETWORK INC |
|
| INDEPENDENT HEALTH (National Association of Insurance Commissioners NAIC id number: 47034 ) |
| Policy contract number | 18479 |
| Policy instance | 6 |
| Insurance contract or identification number | 18479 | | Number of Individuals Covered | 913 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $60,000 | | Health Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 60000 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | LAWLEY BENEFITS GROUP, LLC |
|
| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
| Policy contract number | ADDS06846 |
| Policy instance | 5 |
| Insurance contract or identification number | ADDS06846 | | Number of Individuals Covered | 131 | | Insurance policy start date | 2016-07-01 | | Insurance policy end date | 2017-06-30 | | Total amount of commissions paid to insurance broker | USD $465 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $4,654 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $465 | | Insurance broker organization code? | 3 | | Insurance broker name | BOND FINANCIAL NETWORK INC |
|
| PROVIDENT LIFE AND CASUALTY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68209 ) |
| Policy contract number | 132878 |
| Policy instance | 4 |
| Insurance contract or identification number | 132878 | | Number of Individuals Covered | 68 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2018-01-01 | | Total amount of commissions paid to insurance broker | USD $6,571 | | Total amount of fees paid to insurance company | USD $992 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $117,510 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,635 | | Amount paid for insurance broker fees | 46 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION PAID | | Insurance broker organization code? | 3 | | Insurance broker name | PLANNED BENEFITS INC |
|
| PROVIDENT LIFE AND CASUALTY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68209 ) |
| Policy contract number | 008836 |
| Policy instance | 3 |
| Insurance contract or identification number | 008836 | | Number of Individuals Covered | 6 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2018-01-01 | | Total amount of commissions paid to insurance broker | USD $492 | | Total amount of fees paid to insurance company | USD $0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $4,763 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $143 | | Insurance broker organization code? | 3 | | Insurance broker name | HARRY E JACOBS |
|
| THE PAUL REVERE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 67598 ) |
| Policy contract number | 0007372621 |
| Policy instance | 2 |
| Insurance contract or identification number | 0007372621 | | Number of Individuals Covered | 39 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2018-01-01 | | Total amount of commissions paid to insurance broker | USD $919 | | Total amount of fees paid to insurance company | USD $0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $18,875 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $363 | | Insurance broker organization code? | 3 | | Insurance broker name | MJB FINANCIAL SERVICES INC |
|
| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
| Policy contract number | 038380G |
| Policy instance | 1 |
| Insurance contract or identification number | 038380G | | Number of Individuals Covered | 749 | | Insurance policy start date | 2016-07-01 | | Insurance policy end date | 2017-06-30 | | Total amount of commissions paid to insurance broker | USD $17,178 | | 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 | ACCIDENTAL DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $151,950 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $11,894 | | Insurance broker organization code? | 3 | | Insurance broker name | BOND FINANCIAL NETWORK INC |
|
| INDEPENDENT HEALTH (National Association of Insurance Commissioners NAIC id number: 47034 ) |
| Policy contract number | 18479 |
| Policy instance | 6 |
| Insurance contract or identification number | 18479 | | Number of Individuals Covered | 917 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $50,000 | | Health Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 50000 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | NORTHWEST INSURANCE SERVICES |
|
| LINCOLN LIFE AND ANNUITY CO OF NY (National Association of Insurance Commissioners NAIC id number: 62057 ) |
| Policy contract number | 000010183111 |
| Policy instance | 7 |
| Insurance contract or identification number | 000010183111 | | Number of Individuals Covered | 175 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $15,779 | | Total amount of fees paid to insurance company | USD $3,156 | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $105,188 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,365 | | Amount paid for insurance broker fees | 3156 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | ROBERT F FAHEY |
|
| LINCOLN LIFE AND ANNUITY CO OF NY (National Association of Insurance Commissioners NAIC id number: 62057 ) |
| Policy contract number | 000010183110 |
| Policy instance | 8 |
| Insurance contract or identification number | 000010183110 | | Number of Individuals Covered | 122 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $6,479 | | Total amount of fees paid to insurance company | USD $1,296 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $43,198 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,203 | | Amount paid for insurance broker fees | 1296 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | ROBERT F FAHEY |
|
| PROVIDENT LIFE AND CASUALTY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68209 ) |
| Policy contract number | 155615 |
| Policy instance | 9 |
| Insurance contract or identification number | 155615 | | Number of Individuals Covered | 26 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2016-01-01 | | Total amount of commissions paid to insurance broker | USD $5,485 | | Total amount of fees paid to insurance company | USD $0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $40,689 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,001 | | Insurance broker organization code? | 3 | | Insurance broker name | ROBERT F FAHEY |
|
| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
| Policy contract number | ADDS06846 |
| Policy instance | 5 |
| Insurance contract or identification number | ADDS06846 | | Number of Individuals Covered | 138 | | Insurance policy start date | 2014-07-01 | | Insurance policy end date | 2015-06-30 | | Total amount of commissions paid to insurance broker | USD $473 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $4,731 | | 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 | BOND FINANCIAL NETWORK INC |
|
| PROVIDENT LIFE AND CASUALTY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68209 ) |
| Policy contract number | 132878 |
| Policy instance | 4 |
| Insurance contract or identification number | 132878 | | Number of Individuals Covered | 83 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2016-01-01 | | Total amount of commissions paid to insurance broker | USD $9,784 | | Total amount of fees paid to insurance company | USD $0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $143,327 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,284 | | Insurance broker organization code? | 3 | | Insurance broker name | PLANNED BENEFITS INC |
|
| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
| Policy contract number | 038380G |
| Policy instance | 1 |
| Insurance contract or identification number | 038380G | | Number of Individuals Covered | 1141 | | Insurance policy start date | 2014-07-01 | | Insurance policy end date | 2015-06-30 | | Total amount of commissions paid to insurance broker | USD $19,736 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $175,443 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $19,736 | | Insurance broker organization code? | 3 | | Insurance broker name | BOND FINANCIAL NETWORK INC |
|
| PROVIDENT LIFE AND CASUALTY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68209 ) |
| Policy contract number | 008836 |
| Policy instance | 3 |
| Insurance contract or identification number | 008836 | | Number of Individuals Covered | 8 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2016-01-01 | | Total amount of commissions paid to insurance broker | USD $634 | | Total amount of fees paid to insurance company | USD $0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $6,110 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $143 | | Insurance broker organization code? | 3 | | Insurance broker name | HARRY E JACOBS |
|
| THE PAUL REVERE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 67598 ) |
| Policy contract number | 073726-21 |
| Policy instance | 2 |
| Insurance contract or identification number | 073726-21 | | Number of Individuals Covered | 46 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2016-01-01 | | Total amount of commissions paid to insurance broker | USD $1,931 | | Total amount of fees paid to insurance company | USD $0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $28,252 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,160 | | Insurance broker organization code? | 3 | | Insurance broker name | BOND FINANCIAL NETWORK INC |
|
| INDEPENDENT HEALTH (National Association of Insurance Commissioners NAIC id number: 95308 ) |
| Policy contract number | 18479 |
| Policy instance | 7 |
| Insurance contract or identification number | 18479 | | Number of Individuals Covered | 10 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $564 | | 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 $564 | | Insurance broker organization code? | 3 | | Insurance broker name | BOND FINANCIAL NETWORK INC |
|
| LINCOLN LIFE AND ANNUITY CO OF NY (National Association of Insurance Commissioners NAIC id number: 62057 ) |
| Policy contract number | 000010183111 |
| Policy instance | 9 |
| Insurance contract or identification number | 000010183111 | | Number of Individuals Covered | 165 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $13,809 | | Total amount of fees paid to insurance company | USD $5,290 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $92,059 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,695 | | Amount paid for insurance broker fees | 5290 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION PAID | | Insurance broker organization code? | 3 | | Insurance broker name | ROBERT F FAHEY |
|
| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
| Policy contract number | ADDS06846 |
| Policy instance | 6 |
| Insurance contract or identification number | ADDS06846 | | Number of Individuals Covered | 117 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $35 | | 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 | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $3,842 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $35 | | Insurance broker organization code? | 3 | | Insurance broker name | BOND FINANCIAL NETWORK INC |
|
| PROVIDENT LIFE AND CASUALTY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68209 ) |
| Policy contract number | 132878 |
| Policy instance | 5 |
| Insurance contract or identification number | 132878 | | Number of Individuals Covered | 86 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2015-01-01 | | Total amount of commissions paid to insurance broker | USD $12,376 | | Total amount of fees paid to insurance company | USD $1,939 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $150,632 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,133 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 1939 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION PAID | | Insurance broker name | PLANNED BENEFITS INC |
|
| THE PAUL REVERE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 67598 ) |
| Policy contract number | 073726-21 |
| Policy instance | 3 |
| Insurance contract or identification number | 073726-21 | | Number of Individuals Covered | 47 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2015-01-01 | | Total amount of commissions paid to insurance broker | USD $2,037 | | 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 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $29,537 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,188 | | Insurance broker organization code? | 3 | | Insurance broker name | ROBERT F FAHEY JR |
|
| PROVIDENT LIFE AND CASUALTY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68209 ) |
| Policy contract number | 008836 |
| Policy instance | 4 |
| Insurance contract or identification number | 008836 | | Number of Individuals Covered | 10 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2015-01-01 | | Total amount of commissions paid to insurance broker | USD $550 | | 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 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $5,238 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $143 | | Insurance broker organization code? | 3 | | Insurance broker name | HARRY E JACOBS |
|
| INDEPENDENT HEALTH (National Association of Insurance Commissioners NAIC id number: 47034 ) |
| Policy contract number | 30312Y |
| Policy instance | 8 |
| Insurance contract or identification number | 30312Y | | Number of Individuals Covered | 679 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $39,115 | | 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 $39,115 | | Insurance broker organization code? | 3 | | Insurance broker name | NORTHWEST INSURANCE SERVICES |
|
| INDEPENDENT HEALTH (National Association of Insurance Commissioners NAIC id number: 47034 ) |
| Policy contract number | 30312K |
| Policy instance | 1 |
| Insurance contract or identification number | 30312K | | Number of Individuals Covered | 241 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $14,541 | | 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 $14,541 | | Insurance broker organization code? | 3 | | Insurance broker name | NORTHWEST INSURANCE SERVICES |
|
| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
| Policy contract number | 038380G |
| Policy instance | 2 |
| Insurance contract or identification number | 038380G | | Number of Individuals Covered | 1117 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $18,980 | | 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 | | Welfare Benefit Premiums Paid to Carrier | USD $168,598 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $18,980 | | Insurance broker organization code? | 3 | | Insurance broker name | BOND FINANCIAL NETWORK INC |
|
| INDEPENDENT HEALTH (National Association of Insurance Commissioners NAIC id number: 47034 ) |
| Policy contract number | 30312Y |
| Policy instance | 8 |
| Insurance contract or identification number | 30312Y | | Number of Individuals Covered | 665 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $28,048 | | 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 $28,048 | | Insurance broker organization code? | 3 | | Insurance broker name | NORTHWEST INSURANCE SERVICES |
|
| INDEPENDENT HEALTH (National Association of Insurance Commissioners NAIC id number: 95308 ) |
| Policy contract number | 30312M |
| Policy instance | 7 |
| Insurance contract or identification number | 30312M | | Number of Individuals Covered | 11 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $410 | | 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 $410 | | Insurance broker organization code? | 3 | | Insurance broker name | NORTHWEST INSURANCE SERVICES |
|
| HARTFORD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 88072 ) |
| Policy contract number | ADDS06846 |
| Policy instance | 6 |
| Insurance contract or identification number | ADDS06846 | | Number of Individuals Covered | 117 | | Insurance policy start date | 2012-07-01 | | Insurance policy end date | 2013-06-30 | | Total amount of commissions paid to insurance broker | USD $299 | | 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 | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $2,990 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $299 | | Insurance broker organization code? | 3 | | Insurance broker name | BOND FINANCIAL NETWORK INC |
|
| THE PAUL REVERE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 67598 ) |
| Policy contract number | 073726-21 |
| Policy instance | 3 |
| Insurance contract or identification number | 073726-21 | | Number of Individuals Covered | 48 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2014-01-01 | | Total amount of commissions paid to insurance broker | USD $2,052 | | 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 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $29,773 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,194 | | Insurance broker organization code? | 3 | | Insurance broker name | ROBERT FAHEY |
|
| HARTFORD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 88072 ) |
| Policy contract number | 038380G |
| Policy instance | 2 |
| Insurance contract or identification number | 038380G | | Number of Individuals Covered | 993 | | Insurance policy start date | 2012-07-01 | | Insurance policy end date | 2013-06-30 | | Total amount of commissions paid to insurance broker | USD $16,357 | | 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 | | Welfare Benefit Premiums Paid to Carrier | USD $144,915 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $16,357 | | Insurance broker organization code? | 3 | | Insurance broker name | BOND FINANCIAL NETWORK INC |
|
| INDEPENDENT HEALTH (National Association of Insurance Commissioners NAIC id number: 47034 ) |
| Policy contract number | 30312K |
| Policy instance | 1 |
| Insurance contract or identification number | 30312K | | Number of Individuals Covered | 211 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $9,043 | | 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 $9,043 | | Insurance broker organization code? | 3 | | Insurance broker name | NORTHWEST INSURANCE SERVICES |
|
| PROVIDENT LIFE AND CASUALTY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68209 ) |
| Policy contract number | 132878 |
| Policy instance | 5 |
| Insurance contract or identification number | 132878 | | Number of Individuals Covered | 86 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2014-01-01 | | Total amount of commissions paid to insurance broker | USD $15,255 | | Total amount of fees paid to insurance company | USD $2,307 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $155,588 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $9,432 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 2307 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION PAID | | Insurance broker name | PLANNED BENEFITS INC |
|
| PROVIDENT LIFE AND CASUALTY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68209 ) |
| Policy contract number | 008836 |
| Policy instance | 4 |
| Insurance contract or identification number | 008836 | | Number of Individuals Covered | 10 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2014-01-01 | | Total amount of commissions paid to insurance broker | USD $604 | | 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 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $5,417 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $180 | | Insurance broker organization code? | 3 | | Insurance broker name | HARRY JACOBS |
|
| HARTFORD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 88072 ) |
| Policy contract number | 038380G |
| Policy instance | 2 |
| Insurance contract or identification number | 038380G | | Number of Individuals Covered | 877 | | Insurance policy start date | 2011-07-01 | | Insurance policy end date | 2012-06-30 | | Total amount of commissions paid to insurance broker | USD $4,735 | | 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 | | Welfare Benefit Premiums Paid to Carrier | USD $47,214 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,735 | | Insurance broker organization code? | 3 | | Insurance broker name | BOND FINANCIAL NETWORK INC |
|
| AMERICAN MEDICAL AND LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 81418 ) |
| Policy contract number | BUFMED |
| Policy instance | 3 |
| Insurance contract or identification number | BUFMED | | Number of Individuals Covered | 564 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | 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 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| THE PAUL REVERE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 67598 ) |
| Policy contract number | 073726-21 |
| Policy instance | 4 |
| Insurance contract or identification number | 073726-21 | | Number of Individuals Covered | 48 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2013-01-01 | | Total amount of commissions paid to insurance broker | USD $2,107 | | 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 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $29,132 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,196 | | Insurance broker organization code? | 3 | | Insurance broker name | ROBERT FAHEY |
|
| PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 ) |
| Policy contract number | 008836 |
| Policy instance | 5 |
| Insurance contract or identification number | 008836 | | Number of Individuals Covered | 10 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $542 | | 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 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $5,417 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $143 | | Insurance broker organization code? | 3 | | Insurance broker name | HARRY JACOBS |
|
| PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 ) |
| Policy contract number | 132878 |
| Policy instance | 6 |
| Insurance contract or identification number | 132878 | | Number of Individuals Covered | 87 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $15,402 | | Total amount of fees paid to insurance company | USD $2,441 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $153,484 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $9,345 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 2441 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION PAID | | Insurance broker name | PLANNED BENEFITS INC |
|
| INDEPENDENT HEALTH (National Association of Insurance Commissioners NAIC id number: 95308 ) |
| Policy contract number | 30312M |
| Policy instance | 8 |
| Insurance contract or identification number | 30312M | | Number of Individuals Covered | 10 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $542 | | 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 $542 | | Insurance broker organization code? | 3 | | Insurance broker name | VERACITY BENEFIT DESIGNS, INC. |
|
| INDEPENDENT HEALTH (National Association of Insurance Commissioners NAIC id number: 47034 ) |
| Policy contract number | 30312Y |
| Policy instance | 9 |
| Insurance contract or identification number | 30312Y | | Number of Individuals Covered | 621 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $40,084 | | 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 $40,084 | | Insurance broker organization code? | 3 | | Insurance broker name | VERACITY BENEFIT DESIGNS, INC. |
|
| HARTFORD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 88072 ) |
| Policy contract number | ADDS06846 |
| Policy instance | 7 |
| Insurance contract or identification number | ADDS06846 | | Number of Individuals Covered | 90 | | Insurance policy start date | 2011-07-01 | | Insurance policy end date | 2012-06-30 | | Total amount of commissions paid to insurance broker | USD $325 | | 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 | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $3,252 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $325 | | Insurance broker organization code? | 3 | | Insurance broker name | BOND FINANCIAL NETWORK INC |
|
| INDEPENDENT HEALTH (National Association of Insurance Commissioners NAIC id number: 47034 ) |
| Policy contract number | 30312K |
| Policy instance | 1 |
| Insurance contract or identification number | 30312K | | Number of Individuals Covered | 180 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $1,354 | | 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 $1,354 | | Insurance broker organization code? | 3 | | Insurance broker name | VERACITY BENEFIT DESIGNS, INC. |
|
| INDEPENDENT HEALTH (National Association of Insurance Commissioners NAIC id number: 47034 ) |
| Policy contract number | 30312 |
| Policy instance | 1 |
| Insurance contract or identification number | 30312 | | Number of Individuals Covered | 759 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2011-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $70,883 | | 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 |
|
| PROVIDENT LIFE AND CASUALTY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68209 ) |
| Policy contract number | 132878 |
| Policy instance | 6 |
| Insurance contract or identification number | 132878 | | Number of Individuals Covered | 88 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2011-12-31 | | Total amount of commissions paid to insurance broker | USD $18,524 | | Total amount of fees paid to insurance company | USD $3,364 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $155,132 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| THE PAUL REVERE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 67598 ) |
| Policy contract number | 073726-21 |
| Policy instance | 4 |
| Insurance contract or identification number | 073726-21 | | Number of Individuals Covered | 48 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2011-12-31 | | Total amount of commissions paid to insurance broker | USD $9,177 | | 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 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $29,132 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HARTFORD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 88072 ) |
| Policy contract number | ADDS06846 |
| Policy instance | 7 |
| Insurance contract or identification number | ADDS06846 | | Number of Individuals Covered | 748 | | Insurance policy start date | 2010-07-01 | | Insurance policy end date | 2011-06-30 | | Total amount of commissions paid to insurance broker | USD $237 | | 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 | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $2,373 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| PROVIDENT LIFE AND CASUALTY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68209 ) |
| Policy contract number | 008836 |
| Policy instance | 5 |
| Insurance contract or identification number | 008836 | | Number of Individuals Covered | 10 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2011-12-31 | | Total amount of commissions paid to insurance broker | USD $542 | | 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 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $5,417 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| AMERICAN MEDICAL AND LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 81418 ) |
| Policy contract number | BUFMED |
| Policy instance | 3 |
| Insurance contract or identification number | BUFMED | | Number of Individuals Covered | 545 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2011-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | 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 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HARTFORD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 88072 ) |
| Policy contract number | 038380G |
| Policy instance | 2 |
| Insurance contract or identification number | 038380G | | Number of Individuals Covered | 954 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2011-12-31 | | Total amount of commissions paid to insurance broker | USD $18,423 | | 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 | | Welfare Benefit Premiums Paid to Carrier | USD $114,882 | | 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: 95308 ) |
| Policy contract number | 30312 |
| Policy instance | 1 |
| Insurance contract or identification number | 30312 | | Number of Individuals Covered | 722 | | Insurance policy start date | 2010-01-01 | | Insurance policy end date | 2010-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $12,501 | | 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 | | Amount paid for insurance broker fees | 12501 | | Additional information about fees paid to insurance broker | CONSULTING FEES | | Insurance broker organization code? | 3 | | Insurance broker name | VERACITY BENEFITS |
|
| HARTFORD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 88072 ) |
| Policy contract number | 038380 |
| Policy instance | 2 |
| Insurance contract or identification number | 038380 | | Number of Individuals Covered | 748 | | Insurance policy start date | 2009-07-01 | | Insurance policy end date | 2010-06-30 | | Total amount of commissions paid to insurance broker | USD $212 | | 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 | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $212 | | Insurance broker organization code? | 3 | | Insurance broker name | BOND FINANCIAL NETWORK INC |
|
| AMERICAN MEDICAL AND LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 81418 ) |
| Policy contract number | BUFMED |
| Policy instance | 3 |
| Insurance contract or identification number | BUFMED | | Number of Individuals Covered | 528 | | Insurance policy start date | 2010-01-01 | | Insurance policy end date | 2010-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | 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 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HARTFORD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 88072 ) |
| Policy contract number | 038380G |
| Policy instance | 4 |
| Insurance contract or identification number | 038380G | | Number of Individuals Covered | 91 | | Insurance policy start date | 2010-01-01 | | Insurance policy end date | 2010-12-31 | | Total amount of commissions paid to insurance broker | USD $12,489 | | 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 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $104,173 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $12,489 | | Insurance broker organization code? | 3 | | Insurance broker name | BOND FINANCIAL NETWORK INC |
|
| PROVIDENT LIFE AND CASUALTY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68209 ) |
| Policy contract number | 132878 |
| Policy instance | 7 |
| Insurance contract or identification number | 132878 | | Number of Individuals Covered | 90 | | Insurance policy start date | 2010-01-01 | | Insurance policy end date | 2010-12-31 | | Total amount of commissions paid to insurance broker | USD $24,111 | | Total amount of fees paid to insurance company | USD $5,920 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $148,571 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $10,246 | | Amount paid for insurance broker fees | 4892 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION PAID | | Insurance broker organization code? | 3 | | Insurance broker name | ERICK BOND |
|
| PROVIDENT LIFE AND CASUALTY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68209 ) |
| Policy contract number | 008836 |
| Policy instance | 6 |
| Insurance contract or identification number | 008836 | | Number of Individuals Covered | 11 | | Insurance policy start date | 2010-01-01 | | Insurance policy end date | 2010-12-31 | | Total amount of commissions paid to insurance broker | USD $541 | | 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 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $5,417 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $143 | | Insurance broker organization code? | 3 | | Insurance broker name | HARRY JACOBS |
|
| THE PAUL REVERE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 67598 ) |
| Policy contract number | 073726-21 |
| Policy instance | 5 |
| Insurance contract or identification number | 073726-21 | | Number of Individuals Covered | 50 | | Insurance policy start date | 2010-01-01 | | Insurance policy end date | 2010-12-31 | | Total amount of commissions paid to insurance broker | USD $2,687 | | Total amount of fees paid to insurance company | USD $45 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $29,282 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,204 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 45 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION PAID | | Insurance broker name | ERIC BOND |
|
