DIEFENTHAL HOLDINGS, LLC has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan DIEFENTHAL HOLDINGS, LLC HEALTH PLAN
| Measure | Date | Value |
|---|
| 2015: DIEFENTHAL HOLDINGS, LLC HEALTH PLAN 2015 401k membership |
|---|
| Total participants, beginning-of-year | 2015-01-01 | 283 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-01-01 | 283 |
| Number of retired or separated participants receiving benefits | 2015-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2015-01-01 | 0 |
| Total of all active and inactive participants | 2015-01-01 | 283 |
| 2014: DIEFENTHAL HOLDINGS, LLC HEALTH PLAN 2014 401k membership |
|---|
| Total participants, beginning-of-year | 2014-01-01 | 585 |
| Total number of active participants reported on line 7a of the Form 5500 | 2014-01-01 | 262 |
| Total of all active and inactive participants | 2014-01-01 | 262 |
| 2013: DIEFENTHAL HOLDINGS, LLC HEALTH PLAN 2013 401k membership |
|---|
| Total participants, beginning-of-year | 2013-01-01 | 200 |
| Total number of active participants reported on line 7a of the Form 5500 | 2013-01-01 | 585 |
| Total of all active and inactive participants | 2013-01-01 | 585 |
| 2012: DIEFENTHAL HOLDINGS, LLC HEALTH PLAN 2012 401k membership |
|---|
| Total participants, beginning-of-year | 2012-01-01 | 325 |
| Total number of active participants reported on line 7a of the Form 5500 | 2012-01-01 | 200 |
| Total of all active and inactive participants | 2012-01-01 | 200 |
| 2011: DIEFENTHAL HOLDINGS, LLC HEALTH PLAN 2011 401k membership |
|---|
| Total participants, beginning-of-year | 2011-01-01 | 325 |
| Total number of active participants reported on line 7a of the Form 5500 | 2011-01-01 | 325 |
| Total of all active and inactive participants | 2011-01-01 | 325 |
| Total participants | 2011-01-01 | 325 |
| 2010: DIEFENTHAL HOLDINGS, LLC HEALTH PLAN 2010 401k membership |
|---|
| Total participants, beginning-of-year | 2010-01-01 | 200 |
| Total number of active participants reported on line 7a of the Form 5500 | 2010-01-01 | 114 |
| Total of all active and inactive participants | 2010-01-01 | 114 |
| 2009: DIEFENTHAL HOLDINGS, LLC HEALTH PLAN 2009 401k membership |
|---|
| Total participants, beginning-of-year | 2009-01-01 | 208 |
| Total number of active participants reported on line 7a of the Form 5500 | 2009-01-01 | 200 |
| Total of all active and inactive participants | 2009-01-01 | 200 |
| 2008: DIEFENTHAL HOLDINGS, LLC HEALTH PLAN 2008 401k membership |
|---|
| Total participants, beginning-of-year | 2008-01-01 | 181 |
| Total number of active participants reported on line 7a of the Form 5500 | 2008-01-01 | 208 |
| Total of all active and inactive participants | 2008-01-01 | 208 |
| 2007: DIEFENTHAL HOLDINGS, LLC HEALTH PLAN 2007 401k membership |
|---|
| Total participants, beginning-of-year | 2007-01-01 | 181 |
| Total number of active participants reported on line 7a of the Form 5500 | 2007-01-01 | 181 |
| Total of all active and inactive participants | 2007-01-01 | 181 |
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80012 ) |
| Policy contract number | 0847503-SHORT |
| Policy instance | 1 |
| Insurance contract or identification number | 0847503-SHORT | | Number of Individuals Covered | 590 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-08-31 | | Total amount of commissions paid to insurance broker | USD $10,656 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $2,006,194 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $10,656 | | Insurance broker organization code? | 3 | | Insurance broker name | ALPHA BENEFITS INC |
|
| AETNA HEALTH, INC. (National Association of Insurance Commissioners NAIC id number: 96518 ) |
| Policy contract number | 0847503HNO-SHOR |
| Policy instance | 2 |
| Insurance contract or identification number | 0847503HNO-SHOR | | Number of Individuals Covered | 131 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-08-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Welfare Benefit Premiums Paid to Carrier | USD $504,266 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
| Policy contract number | 875525G |
| Policy instance | 3 |
| Insurance contract or identification number | 875525G | | Number of Individuals Covered | 286 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $10,988 | | Total amount of fees paid to insurance company | USD $7,013 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $140,368 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $10,988 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 7013 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker name | EXPRESSLINK GENERAL AGENCY |
|
| HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93440 ) |
| Policy contract number | 5015020010VIO |
| Policy instance | 2 |
| Insurance contract or identification number | 5015020010VIO | | Number of Individuals Covered | 167 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | 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 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $29,213 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80012 ) |
| Policy contract number | 0847503 |
| Policy instance | 1 |
| Insurance contract or identification number | 0847503 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | 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 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $3,243,205 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| AETNA HEALTH INC. (National Association of Insurance Commissioners NAIC id number: 95002 ) |
| Policy contract number | 0847503HNO |
| Policy instance | 1 |
| Insurance contract or identification number | 0847503HNO | | Number of Individuals Covered | 159 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | 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 | | Welfare Benefit Premiums Paid to Carrier | USD $575,263 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80012 ) |
| Policy contract number | 0847503 |
| Policy instance | 2 |
| Insurance contract or identification number | 0847503 | | Number of Individuals Covered | 585 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $20,507 | | Total amount of fees paid to insurance company | USD $2,766 | | 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 | | Dental Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $1,662,316 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $20,507 | | Amount paid for insurance broker fees | 2766 | | Additional information about fees paid to insurance broker | 1Q SPECIALTY CROSS SALE AND PM CROSS-SALE | | Insurance broker organization code? | 3 | | Insurance broker name | ALPHA BENEFITS INC |
|
| HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93440 ) |
| Policy contract number | 5015020010VIO |
| Policy instance | 3 |
| Insurance contract or identification number | 5015020010VIO | | Number of Individuals Covered | 167 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | 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 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $15,478 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $0 | | Insurance broker organization code? | 3 | | Insurance broker name | PATRICK PLATTEN |
|
| PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 ) |
| Policy contract number | 01940 |
| Policy instance | 4 |
| Insurance contract or identification number | 01940 | | Number of Individuals Covered | 195 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $420 | | 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 | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $11,530 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $420 | | Additional information about fees paid to insurance broker | SALES AND SERVICE COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | ALPHA BENEFITS INC |
|
| HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93440 ) |
| Policy contract number | 5015020010VIO |
| Policy instance | 2 |
| Insurance contract or identification number | 5015020010VIO | | Number of Individuals Covered | 84 | | 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 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $10,934 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $0 | | Insurance broker organization code? | 3 | | Insurance broker name | PATRICK PLATTEN |
|
| DELTA DENTAL OF OHIO (National Association of Insurance Commissioners NAIC id number: 54402 ) |
| Policy contract number | 1405 |
| Policy instance | 3 |
| Insurance contract or identification number | 1405 | | Number of Individuals Covered | 176 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $3,386 | | 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 | | Commission paid to Insurance Broker | USD $2,647 | | Insurance broker organization code? | 3 | | Insurance broker name | |
|
| PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 ) |
| Policy contract number | 01940 |
| Policy instance | 1 |
| Insurance contract or identification number | 01940 | | Number of Individuals Covered | 200 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $8,649 | | 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 | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $146,447 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,649 | | Additional information about fees paid to insurance broker | SALES AND SERVICE | | Insurance broker organization code? | 3 | | Insurance broker name | ALPHA BENEFITS INC. |
|
| PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 ) |
| Policy contract number | 01940 |
| Policy instance | 1 |
| Insurance contract or identification number | 01940 | | Number of Individuals Covered | 172 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2011-12-31 | | Total amount of commissions paid to insurance broker | USD $6,629 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $109,272 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93440 ) |
| Policy contract number | 5015020010VIO |
| Policy instance | 2 |
| Insurance contract or identification number | 5015020010VIO | | Number of Individuals Covered | 65 | | 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 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $5,868 |
|
| DELTA DENTAL OF OHIO (National Association of Insurance Commissioners NAIC id number: 54402 ) |
| Policy contract number | 1405 |
| Policy instance | 3 |
| Insurance contract or identification number | 1405 | | Number of Individuals Covered | 167 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2011-12-31 | | Total amount of commissions paid to insurance broker | USD $2,584 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 716286 |
| Policy instance | 4 |
| Insurance contract or identification number | 716286 | | Number of Individuals Covered | 325 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2011-12-31 | | Total amount of commissions paid to insurance broker | USD $-14,361 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $1,285,323 |
|
| PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 ) |
| Policy contract number | 01940 |
| Policy instance | 1 |
| Insurance contract or identification number | 01940 | | Number of Individuals Covered | 114 | | Insurance policy start date | 2010-01-01 | | Insurance policy end date | 2010-12-31 | | Total amount of commissions paid to insurance broker | USD $7,609 | | 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 | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $107,266 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,609 | | Additional information about fees paid to insurance broker | SALES AND SERVICE COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | ALPHA BENEFITS INC |
|
| DELTA DENTAL OF OHIO (National Association of Insurance Commissioners NAIC id number: 54402 ) |
| Policy contract number | 1405 |
| Policy instance | 2 |
| Insurance contract or identification number | 1405 | | Number of Individuals Covered | 175 | | Insurance policy start date | 2010-01-01 | | Insurance policy end date | 2010-12-31 | | Total amount of commissions paid to insurance broker | USD $3,054 | | 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 | | Commission paid to Insurance Broker | USD $3,054 | | Insurance broker organization code? | 3 | | Insurance broker name | ALPHA BENEFITS INC |
|
| HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93440 ) |
| Policy contract number | DFH 001,COB |
| Policy instance | 3 |
| Insurance contract or identification number | DFH 001,COB | | Number of Individuals Covered | 115 | | 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 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $6,580 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $0 | | Insurance broker name | |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 716286 |
| Policy instance | 4 |
| Insurance contract or identification number | 716286 | | Number of Individuals Covered | 325 | | Insurance policy start date | 2010-01-01 | | Insurance policy end date | 2010-12-31 | | Total amount of commissions paid to insurance broker | USD $47,670 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,444,224 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $47,670 | | Insurance broker organization code? | 3 | | Insurance broker name | EMPLOYERS SELECT PLAN AGENCY INC. |
|
| DELTA DENTAL OF OHIO (National Association of Insurance Commissioners NAIC id number: 54402 ) |
| Policy contract number | 1405 |
| Policy instance | 1 |
| Insurance contract or identification number | 1405 | | Number of Individuals Covered | 194 | | Insurance policy start date | 2009-01-01 | | Insurance policy end date | 2009-12-31 | | Total amount of commissions paid to insurance broker | USD $2,616 | | 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 | | Commission paid to Insurance Broker | USD $2,616 | | Insurance broker organization code? | 3 | | Insurance broker name | PATRICK PLATTEN |
|
| HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93440 ) |
| Policy contract number | DFH 001, COB |
| Policy instance | 2 |
| Insurance contract or identification number | DFH 001, COB | | Number of Individuals Covered | 187 | | Insurance policy start date | 2009-01-01 | | Insurance policy end date | 2009-12-31 | | 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 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $633 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 ) |
| Policy contract number | 01940 |
| Policy instance | 3 |
| Insurance contract or identification number | 01940 | | Number of Individuals Covered | 200 | | Insurance policy start date | 2009-01-01 | | Insurance policy end date | 2009-12-31 | | Total amount of commissions paid to insurance broker | USD $6,672 | | 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 | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $74,067 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,672 | | Additional information about fees paid to insurance broker | SALES AND SERVICES | | Insurance broker organization code? | 3 | | Insurance broker name | PATRICK PLATTEN |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 716286 |
| Policy instance | 4 |
| Insurance contract or identification number | 716286 | | Number of Individuals Covered | 558 | | Insurance policy start date | 2009-01-01 | | Insurance policy end date | 2009-12-31 | | 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 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $117,798 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93440 ) |
| Policy contract number | DFH 001,COB |
| Policy instance | 2 |
| Insurance contract or identification number | DFH 001,COB | | Number of Individuals Covered | 115 | | Insurance policy start date | 2008-01-01 | | Insurance policy end date | 2008-12-31 | | 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 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $5,254 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| DELTA DENTAL OF OHIO (National Association of Insurance Commissioners NAIC id number: 54402 ) |
| Policy contract number | 1405 |
| Policy instance | 1 |
| Insurance contract or identification number | 1405 | | Number of Individuals Covered | 208 | | Insurance policy start date | 2008-01-01 | | Insurance policy end date | 2008-12-31 | | Total amount of commissions paid to insurance broker | USD $2,750 | | 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 | | Commission paid to Insurance Broker | USD $2,750 | | Insurance broker organization code? | 3 | | Insurance broker name | ALPHA BENEFITS INC |
|
| DELTA DENTAL OF OHIO (National Association of Insurance Commissioners NAIC id number: 54402 ) |
| Policy contract number | 1405 |
| Policy instance | 1 |
| Insurance contract or identification number | 1405 | | Number of Individuals Covered | 181 | | Insurance policy start date | 2007-01-01 | | Insurance policy end date | 2007-12-31 | | Total amount of commissions paid to insurance broker | USD $1,851 | | 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 | | Commission paid to Insurance Broker | USD $1,851 | | Insurance broker name | |
|
| HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93440 ) |
| Policy contract number | DFH 001, COB |
| Policy instance | 2 |
| Insurance contract or identification number | DFH 001, COB | | Number of Individuals Covered | 115 | | Insurance policy start date | 2007-01-01 | | Insurance policy end date | 2007-12-31 | | 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 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,154 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
