RYAN AUTOMOTIVE LLC DBA OPEN ROAD AUTO GROUP has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan RYAN AUTOMOTIVE LLC DBA OPEN ROAD AUTO GROUP EMPLOYEE BENEFITS PLAN
401k plan membership statisitcs for RYAN AUTOMOTIVE LLC DBA OPEN ROAD AUTO GROUP EMPLOYEE BENEFITS PLAN
| Measure | Date | Value |
|---|
| 2022: RYAN AUTOMOTIVE LLC DBA OPEN ROAD AUTO GROUP EMPLOYEE BENEFITS PLAN 2022 401k membership |
|---|
| Total participants, beginning-of-year | 2022-09-01 | 494 |
| Total number of active participants reported on line 7a of the Form 5500 | 2022-09-01 | 461 |
| Number of retired or separated participants receiving benefits | 2022-09-01 | 8 |
| Number of other retired or separated participants entitled to future benefits | 2022-09-01 | 0 |
| Total of all active and inactive participants | 2022-09-01 | 469 |
| 2021: RYAN AUTOMOTIVE LLC DBA OPEN ROAD AUTO GROUP EMPLOYEE BENEFITS PLAN 2021 401k membership |
|---|
| Total participants, beginning-of-year | 2021-09-01 | 508 |
| Total number of active participants reported on line 7a of the Form 5500 | 2021-09-01 | 450 |
| Number of retired or separated participants receiving benefits | 2021-09-01 | 9 |
| Number of other retired or separated participants entitled to future benefits | 2021-09-01 | 0 |
| Total of all active and inactive participants | 2021-09-01 | 459 |
| 2020: RYAN AUTOMOTIVE LLC DBA OPEN ROAD AUTO GROUP EMPLOYEE BENEFITS PLAN 2020 401k membership |
|---|
| Total participants, beginning-of-year | 2020-09-01 | 917 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-09-01 | 945 |
| Number of retired or separated participants receiving benefits | 2020-09-01 | 7 |
| Number of other retired or separated participants entitled to future benefits | 2020-09-01 | 0 |
| Total of all active and inactive participants | 2020-09-01 | 952 |
| 2019: RYAN AUTOMOTIVE LLC DBA OPEN ROAD AUTO GROUP EMPLOYEE BENEFITS PLAN 2019 401k membership |
|---|
| Total participants, beginning-of-year | 2019-09-01 | 965 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-09-01 | 936 |
| Number of retired or separated participants receiving benefits | 2019-09-01 | 4 |
| Number of other retired or separated participants entitled to future benefits | 2019-09-01 | 0 |
| Total of all active and inactive participants | 2019-09-01 | 940 |
| 2018: RYAN AUTOMOTIVE LLC DBA OPEN ROAD AUTO GROUP EMPLOYEE BENEFITS PLAN 2018 401k membership |
|---|
| Total participants, beginning-of-year | 2018-09-01 | 948 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-09-01 | 978 |
| Number of retired or separated participants receiving benefits | 2018-09-01 | 20 |
| Number of other retired or separated participants entitled to future benefits | 2018-09-01 | 0 |
| Total of all active and inactive participants | 2018-09-01 | 998 |
| 2017: RYAN AUTOMOTIVE LLC DBA OPEN ROAD AUTO GROUP EMPLOYEE BENEFITS PLAN 2017 401k membership |
|---|
| Total participants, beginning-of-year | 2017-09-01 | 941 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-09-01 | 936 |
| Number of retired or separated participants receiving benefits | 2017-09-01 | 14 |
| Number of other retired or separated participants entitled to future benefits | 2017-09-01 | 0 |
| Total of all active and inactive participants | 2017-09-01 | 950 |
| 2016: RYAN AUTOMOTIVE LLC DBA OPEN ROAD AUTO GROUP EMPLOYEE BENEFITS PLAN 2016 401k membership |
|---|
| Total participants, beginning-of-year | 2016-09-01 | 894 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-09-01 | 927 |
| Number of retired or separated participants receiving benefits | 2016-09-01 | 16 |
| Number of other retired or separated participants entitled to future benefits | 2016-09-01 | 0 |
| Total of all active and inactive participants | 2016-09-01 | 943 |
| 2015: RYAN AUTOMOTIVE LLC DBA OPEN ROAD AUTO GROUP EMPLOYEE BENEFITS PLAN 2015 401k membership |
|---|
| Total participants, beginning-of-year | 2015-09-01 | 613 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-09-01 | 813 |
| Number of retired or separated participants receiving benefits | 2015-09-01 | 12 |
| Number of other retired or separated participants entitled to future benefits | 2015-09-01 | 0 |
| Total of all active and inactive participants | 2015-09-01 | 825 |
| 2014: RYAN AUTOMOTIVE LLC DBA OPEN ROAD AUTO GROUP EMPLOYEE BENEFITS PLAN 2014 401k membership |
|---|
| Total participants, beginning-of-year | 2014-09-01 | 468 |
| Total number of active participants reported on line 7a of the Form 5500 | 2014-09-01 | 613 |
| Number of retired or separated participants receiving benefits | 2014-09-01 | 19 |
| Number of other retired or separated participants entitled to future benefits | 2014-09-01 | 0 |
| Total of all active and inactive participants | 2014-09-01 | 632 |
| 2013: RYAN AUTOMOTIVE LLC DBA OPEN ROAD AUTO GROUP EMPLOYEE BENEFITS PLAN 2013 401k membership |
|---|
| Total participants, beginning-of-year | 2013-09-01 | 557 |
| Total number of active participants reported on line 7a of the Form 5500 | 2013-09-01 | 468 |
| Number of retired or separated participants receiving benefits | 2013-09-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2013-09-01 | 0 |
| Total of all active and inactive participants | 2013-09-01 | 468 |
| 2012: RYAN AUTOMOTIVE LLC DBA OPEN ROAD AUTO GROUP EMPLOYEE BENEFITS PLAN 2012 401k membership |
|---|
| Total participants, beginning-of-year | 2012-09-01 | 578 |
| Total number of active participants reported on line 7a of the Form 5500 | 2012-09-01 | 547 |
| Number of retired or separated participants receiving benefits | 2012-09-01 | 10 |
| Number of other retired or separated participants entitled to future benefits | 2012-09-01 | 0 |
| Total of all active and inactive participants | 2012-09-01 | 557 |
| 2011: RYAN AUTOMOTIVE LLC DBA OPEN ROAD AUTO GROUP EMPLOYEE BENEFITS PLAN 2011 401k membership |
|---|
| Total participants, beginning-of-year | 2011-09-01 | 592 |
| Total number of active participants reported on line 7a of the Form 5500 | 2011-09-01 | 580 |
| Number of retired or separated participants receiving benefits | 2011-09-01 | 17 |
| Number of other retired or separated participants entitled to future benefits | 2011-09-01 | 0 |
| Total of all active and inactive participants | 2011-09-01 | 597 |
| Total participants, beginning-of-year | 2011-01-01 | 592 |
| Total number of active participants reported on line 7a of the Form 5500 | 2011-01-01 | 580 |
| Number of retired or separated participants receiving benefits | 2011-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2011-01-01 | 0 |
| Total of all active and inactive participants | 2011-01-01 | 580 |
| Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits | 2011-01-01 | 0 |
| Total participants | 2011-01-01 | 580 |
| Number of participants with account balances | 2011-01-01 | 0 |
| Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested | 2011-01-01 | 0 |
| 2009: RYAN AUTOMOTIVE LLC DBA OPEN ROAD AUTO GROUP EMPLOYEE BENEFITS PLAN 2009 401k membership |
|---|
| Total participants, beginning-of-year | 2009-09-01 | 453 |
| Total number of active participants reported on line 7a of the Form 5500 | 2009-09-01 | 601 |
| Number of retired or separated participants receiving benefits | 2009-09-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2009-09-01 | 0 |
| Total of all active and inactive participants | 2009-09-01 | 601 |
| Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits | 2009-09-01 | 0 |
| Total participants | 2009-09-01 | 601 |
| Number of participants with account balances | 2009-09-01 | 0 |
| Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested | 2009-09-01 | 0 |
| 2008: RYAN AUTOMOTIVE LLC DBA OPEN ROAD AUTO GROUP EMPLOYEE BENEFITS PLAN 2008 401k membership |
|---|
| Total participants, beginning-of-year | 2008-09-01 | 488 |
| Total number of active participants reported on line 7a of the Form 5500 | 2008-09-01 | 492 |
| Number of retired or separated participants receiving benefits | 2008-09-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2008-09-01 | 0 |
| Total of all active and inactive participants | 2008-09-01 | 492 |
| Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits | 2008-09-01 | 0 |
| Total participants | 2008-09-01 | 492 |
| Number of participants with account balances | 2008-09-01 | 0 |
| Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested | 2008-09-01 | 0 |
| 2022: RYAN AUTOMOTIVE LLC DBA OPEN ROAD AUTO GROUP EMPLOYEE BENEFITS PLAN 2022 form 5500 responses |
|---|
| 2022-09-01 | Type of plan entity | Single employer plan |
| 2022-09-01 | Submission has been amended | No |
| 2022-09-01 | This submission is the final filing | No |
| 2022-09-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2022-09-01 | Plan is a collectively bargained plan | No |
| 2022-09-01 | Plan funding arrangement – Insurance | Yes |
| 2022-09-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2022-09-01 | Plan benefit arrangement – Insurance | Yes |
| 2022-09-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2021: RYAN AUTOMOTIVE LLC DBA OPEN ROAD AUTO GROUP EMPLOYEE BENEFITS PLAN 2021 form 5500 responses |
|---|
| 2021-09-01 | Type of plan entity | Single employer plan |
| 2021-09-01 | Submission has been amended | No |
| 2021-09-01 | This submission is the final filing | No |
| 2021-09-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2021-09-01 | Plan is a collectively bargained plan | No |
| 2021-09-01 | Plan funding arrangement – Insurance | Yes |
| 2021-09-01 | Plan benefit arrangement – Insurance | Yes |
| 2020: RYAN AUTOMOTIVE LLC DBA OPEN ROAD AUTO GROUP EMPLOYEE BENEFITS PLAN 2020 form 5500 responses |
|---|
| 2020-09-01 | Type of plan entity | Single employer plan |
| 2020-09-01 | Submission has been amended | No |
| 2020-09-01 | This submission is the final filing | No |
| 2020-09-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2020-09-01 | Plan is a collectively bargained plan | No |
| 2020-09-01 | Plan funding arrangement – Insurance | Yes |
| 2020-09-01 | Plan benefit arrangement – Insurance | Yes |
| 2019: RYAN AUTOMOTIVE LLC DBA OPEN ROAD AUTO GROUP EMPLOYEE BENEFITS PLAN 2019 form 5500 responses |
|---|
| 2019-09-01 | Type of plan entity | Single employer plan |
| 2019-09-01 | Submission has been amended | No |
| 2019-09-01 | This submission is the final filing | No |
| 2019-09-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2019-09-01 | Plan is a collectively bargained plan | No |
| 2019-09-01 | Plan funding arrangement – Insurance | Yes |
| 2019-09-01 | Plan benefit arrangement – Insurance | Yes |
| 2018: RYAN AUTOMOTIVE LLC DBA OPEN ROAD AUTO GROUP EMPLOYEE BENEFITS PLAN 2018 form 5500 responses |
|---|
| 2018-09-01 | Type of plan entity | Single employer plan |
| 2018-09-01 | Submission has been amended | No |
| 2018-09-01 | This submission is the final filing | No |
| 2018-09-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2018-09-01 | Plan is a collectively bargained plan | No |
| 2018-09-01 | Plan funding arrangement – Insurance | Yes |
| 2018-09-01 | Plan benefit arrangement – Insurance | Yes |
| 2017: RYAN AUTOMOTIVE LLC DBA OPEN ROAD AUTO GROUP EMPLOYEE BENEFITS PLAN 2017 form 5500 responses |
|---|
| 2017-09-01 | Type of plan entity | Single employer plan |
| 2017-09-01 | Submission has been amended | No |
| 2017-09-01 | This submission is the final filing | No |
| 2017-09-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2017-09-01 | Plan is a collectively bargained plan | No |
| 2017-09-01 | Plan funding arrangement – Insurance | Yes |
| 2017-09-01 | Plan benefit arrangement – Insurance | Yes |
| 2016: RYAN AUTOMOTIVE LLC DBA OPEN ROAD AUTO GROUP EMPLOYEE BENEFITS PLAN 2016 form 5500 responses |
|---|
| 2016-09-01 | Type of plan entity | Single employer plan |
| 2016-09-01 | Submission has been amended | No |
| 2016-09-01 | This submission is the final filing | No |
| 2016-09-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2016-09-01 | Plan is a collectively bargained plan | No |
| 2016-09-01 | Plan funding arrangement – Insurance | Yes |
| 2016-09-01 | Plan benefit arrangement – Insurance | Yes |
| 2015: RYAN AUTOMOTIVE LLC DBA OPEN ROAD AUTO GROUP EMPLOYEE BENEFITS PLAN 2015 form 5500 responses |
|---|
| 2015-09-01 | Type of plan entity | Single employer plan |
| 2015-09-01 | Submission has been amended | No |
| 2015-09-01 | This submission is the final filing | No |
| 2015-09-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2015-09-01 | Plan is a collectively bargained plan | No |
| 2015-09-01 | Plan funding arrangement – Insurance | Yes |
| 2015-09-01 | Plan benefit arrangement – Insurance | Yes |
| 2014: RYAN AUTOMOTIVE LLC DBA OPEN ROAD AUTO GROUP EMPLOYEE BENEFITS PLAN 2014 form 5500 responses |
|---|
| 2014-09-01 | Type of plan entity | Single employer plan |
| 2014-09-01 | Submission has been amended | No |
| 2014-09-01 | This submission is the final filing | No |
| 2014-09-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2014-09-01 | Plan is a collectively bargained plan | No |
| 2014-09-01 | Plan funding arrangement – Insurance | Yes |
| 2014-09-01 | Plan benefit arrangement – Insurance | Yes |
| 2013: RYAN AUTOMOTIVE LLC DBA OPEN ROAD AUTO GROUP EMPLOYEE BENEFITS PLAN 2013 form 5500 responses |
|---|
| 2013-09-01 | Type of plan entity | Single employer plan |
| 2013-09-01 | Submission has been amended | No |
| 2013-09-01 | This submission is the final filing | No |
| 2013-09-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2013-09-01 | Plan is a collectively bargained plan | No |
| 2013-09-01 | Plan funding arrangement – Insurance | Yes |
| 2013-09-01 | Plan benefit arrangement – Insurance | Yes |
| 2012: RYAN AUTOMOTIVE LLC DBA OPEN ROAD AUTO GROUP EMPLOYEE BENEFITS PLAN 2012 form 5500 responses |
|---|
| 2012-09-01 | Type of plan entity | Single employer plan |
| 2012-09-01 | Submission has been amended | No |
| 2012-09-01 | This submission is the final filing | No |
| 2012-09-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2012-09-01 | Plan is a collectively bargained plan | No |
| 2012-09-01 | Plan funding arrangement – Insurance | Yes |
| 2012-09-01 | Plan benefit arrangement – Insurance | Yes |
| 2011: RYAN AUTOMOTIVE LLC DBA OPEN ROAD AUTO GROUP EMPLOYEE BENEFITS PLAN 2011 form 5500 responses |
|---|
| 2011-09-01 | Type of plan entity | Single employer plan |
| 2011-09-01 | Submission has been amended | Yes |
| 2011-09-01 | This submission is the final filing | No |
| 2011-09-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2011-09-01 | Plan is a collectively bargained plan | No |
| 2011-09-01 | Plan funding arrangement – Insurance | Yes |
| 2011-09-01 | Plan benefit arrangement – Insurance | Yes |
| 2011-01-01 | Type of plan entity | Single employer plan |
| 2011-01-01 | First time form 5500 has been submitted | Yes |
| 2011-01-01 | Submission has been amended | No |
| 2011-01-01 | This submission is the final filing | No |
| 2011-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2011-01-01 | Plan is a collectively bargained plan | No |
| 2011-01-01 | Plan funding arrangement – Insurance | Yes |
| 2011-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2009: RYAN AUTOMOTIVE LLC DBA OPEN ROAD AUTO GROUP EMPLOYEE BENEFITS PLAN 2009 form 5500 responses |
|---|
| 2009-09-01 | Type of plan entity | Single employer plan |
| 2009-09-01 | Submission has been amended | Yes |
| 2009-09-01 | This submission is the final filing | No |
| 2009-09-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2009-09-01 | Plan is a collectively bargained plan | No |
| 2009-09-01 | Plan funding arrangement – Insurance | Yes |
| 2009-09-01 | Plan benefit arrangement – Insurance | Yes |
| 2008: RYAN AUTOMOTIVE LLC DBA OPEN ROAD AUTO GROUP EMPLOYEE BENEFITS PLAN 2008 form 5500 responses |
|---|
| 2008-09-01 | Type of plan entity | Single employer plan |
| 2008-09-01 | Submission has been amended | No |
| 2008-09-01 | This submission is the final filing | No |
| 2008-09-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2008-09-01 | Plan is a collectively bargained plan | No |
| 2008-09-01 | Plan funding arrangement – Insurance | Yes |
| 2008-09-01 | Plan benefit arrangement – Insurance | Yes |
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 00577133 |
| Policy instance | 2 |
| Insurance contract or identification number | 00577133 | | Number of Individuals Covered | 929 | | Insurance policy start date | 2022-09-01 | | Insurance policy end date | 2023-08-31 | | Total amount of commissions paid to insurance broker | USD $74,008 | | Total amount of fees paid to insurance company | USD $21,172 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | Yes | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | AD&D, SUPPLEMENTAL LIFE, DEPENDENT LIFE, ACCIDENT, CRITICAL ILLNESS, HOSPITAL INDEMNITY | | 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 $814,457 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $74,008 | | Amount paid for insurance broker fees | 21172 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker organization code? | 3 |
|
| NORTH AMERICAN SPECIALTY INSURANCE CO (National Association of Insurance Commissioners NAIC id number: 29874 ) |
| Policy contract number | ESL 8000055 00 |
| Policy instance | 1 |
| Insurance contract or identification number | ESL 8000055 00 | | Number of Individuals Covered | 446 | | Insurance policy start date | 2022-09-01 | | Insurance policy end date | 2023-08-31 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | 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 $547,429 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 00577133 |
| Policy instance | 2 |
| Insurance contract or identification number | 00577133 | | Number of Individuals Covered | 923 | | Insurance policy start date | 2021-09-01 | | Insurance policy end date | 2022-08-31 | | Total amount of commissions paid to insurance broker | USD $72,047 | | Total amount of fees paid to insurance company | USD $19,070 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | Yes | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | AD&D, SUPPLEMENTAL LIFE, DEPENDENT LIFE, ACCIDENT, CRITICAL ILLNESS, HOSPITAL INDEMNITY | | 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 $818,645 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $72,047 | | Amount paid for insurance broker fees | 19070 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker organization code? | 3 |
|
| WESTPOINT INSURANCE CORPORATION (National Association of Insurance Commissioners NAIC id number: 39845 ) |
| Policy contract number | ESL 8000055 00 |
| Policy instance | 1 |
| Insurance contract or identification number | ESL 8000055 00 | | Number of Individuals Covered | 446 | | Insurance policy start date | 2021-09-01 | | Insurance policy end date | 2022-08-31 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | 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 $579,004 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 00577133 |
| Policy instance | 2 |
| Insurance contract or identification number | 00577133 | | Number of Individuals Covered | 945 | | Insurance policy start date | 2020-09-01 | | Insurance policy end date | 2021-08-31 | | Total amount of commissions paid to insurance broker | USD $71,569 | | Total amount of fees paid to insurance company | USD $14,098 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | Yes | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | AD&D, SUPPLEMENTAL LIFE, DEPENDENT LIFE, ACCIDENT, CRITICAL ILLNESS, HOSPITAL INDEMNITY | | 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 $801,661 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $71,569 | | Amount paid for insurance broker fees | 14098 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker organization code? | 3 |
|
| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
| Policy contract number | 3340055 |
| Policy instance | 1 |
| Insurance contract or identification number | 3340055 | | Number of Individuals Covered | 847 | | Insurance policy start date | 2020-09-01 | | Insurance policy end date | 2021-08-31 | | Total amount of commissions paid to insurance broker | USD $144,561 | | Total amount of fees paid to insurance company | USD $59,143 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | 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 $869,956 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $140,528 | | Amount paid for insurance broker fees | 71 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | OK968968 |
| Policy instance | 5 |
| Insurance contract or identification number | OK968968 | | Number of Individuals Covered | 936 | | Insurance policy start date | 2019-09-01 | | Insurance policy end date | 2020-08-31 | | Total amount of commissions paid to insurance broker | USD $347 | | Total amount of fees paid to insurance company | USD $219 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | AD&D | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $2,313 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $347 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 219 | | Additional information about fees paid to insurance broker | FEES |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | VDT962179 |
| Policy instance | 2 |
| Insurance contract or identification number | VDT962179 | | Number of Individuals Covered | 345 | | Insurance policy start date | 2019-09-01 | | Insurance policy end date | 2020-08-31 | | Total amount of commissions paid to insurance broker | USD $7,148 | | Total amount of fees paid to insurance company | USD $7,025 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | No | | Temporary Disability Insurance Welfare Benefit | No | | 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 $71,511 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,148 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 7025 | | Additional information about fees paid to insurance broker | FEES |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | FLX967457 |
| Policy instance | 6 |
| Insurance contract or identification number | FLX967457 | | Number of Individuals Covered | 326 | | Insurance policy start date | 2019-09-01 | | Insurance policy end date | 2020-08-31 | | Total amount of commissions paid to insurance broker | USD $9,266 | | Total amount of fees paid to insurance company | USD $8,892 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | VOLUNTARY SUPPLEMENTAL LIFE, DEPENDENT LIFE | | 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 $92,368 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $9,266 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 8892 | | Additional information about fees paid to insurance broker | FEES |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 00564156 |
| Policy instance | 7 |
| Insurance contract or identification number | 00564156 | | Number of Individuals Covered | 364 | | Insurance policy start date | 2019-09-01 | | Insurance policy end date | 2020-08-31 | | Total amount of commissions paid to insurance broker | USD $83,872 | | Total amount of fees paid to insurance company | USD $2,893 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENT, CRITICAL ILLNESS, HOSPITAL INDEMNITY | | 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 $140,130 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $83,872 | | Amount paid for insurance broker fees | 2893 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker organization code? | 3 |
|
| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
| Policy contract number | 3340055 |
| Policy instance | 1 |
| Insurance contract or identification number | 3340055 | | Number of Individuals Covered | 1009 | | Insurance policy start date | 2019-09-01 | | Insurance policy end date | 2020-08-31 | | Total amount of commissions paid to insurance broker | USD $133,468 | | Total amount of fees paid to insurance company | USD $54,970 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | Yes | | 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 | | Other welfare benefits provided | PREPAID DENTAL | | 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 $1,258,619 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $133,468 | | Amount paid for insurance broker fees | 54970 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | FLX967456 |
| Policy instance | 4 |
| Insurance contract or identification number | FLX967456 | | Number of Individuals Covered | 936 | | Insurance policy start date | 2019-09-01 | | Insurance policy end date | 2020-08-31 | | Total amount of commissions paid to insurance broker | USD $842 | | Total amount of fees paid to insurance company | USD $699 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | 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 $7,396 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $842 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 699 | | Additional information about fees paid to insurance broker | FEES |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | VDT962178 |
| Policy instance | 3 |
| Insurance contract or identification number | VDT962178 | | Number of Individuals Covered | 381 | | Insurance policy start date | 2019-09-01 | | Insurance policy end date | 2020-08-31 | | Total amount of commissions paid to insurance broker | USD $3,441 | | Total amount of fees paid to insurance company | USD $3,478 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | No | | Temporary Disability Insurance Welfare Benefit | Yes | | 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 $34,669 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 3478 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker organization code? | 3 | | Commission paid to Insurance Broker | USD $3,441 |
|
| CIGNA DENTAL HEALTH OF NEW JERSEY, INC. (National Association of Insurance Commissioners NAIC id number: 11167 ) |
| Policy contract number | 3340055 |
| Policy instance | 8 |
| Insurance contract or identification number | 3340055 | | Number of Individuals Covered | 47 | | Insurance policy start date | 2019-09-01 | | Insurance policy end date | 2020-08-31 | | Total amount of commissions paid to insurance broker | USD $705 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | | Welfare Benefit Premiums Paid to Carrier | USD $13,800 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $705 | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | FLX967457 |
| Policy instance | 6 |
| Insurance contract or identification number | FLX967457 | | Number of Individuals Covered | 355 | | Insurance policy start date | 2018-09-01 | | Insurance policy end date | 2019-08-30 | | Total amount of commissions paid to insurance broker | USD $16,921 | | Total amount of fees paid to insurance company | USD $8,335 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | VOLUNTARY SUPPLEMENTAL LIFE AND DEPENDENT LIFE | | 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 $170,014 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $16,921 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 8335 | | Additional information about fees paid to insurance broker | FEES |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | OK968968 |
| Policy instance | 5 |
| Insurance contract or identification number | OK968968 | | Number of Individuals Covered | 978 | | Insurance policy start date | 2018-09-01 | | Insurance policy end date | 2019-08-31 | | Total amount of commissions paid to insurance broker | USD $508 | | Total amount of fees paid to insurance company | USD $166 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | AD&D | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $3,382 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $508 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 166 | | Additional information about fees paid to insurance broker | FEES |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | VDT962178 |
| Policy instance | 3 |
| Insurance contract or identification number | VDT962178 | | Number of Individuals Covered | 449 | | Insurance policy start date | 2018-09-01 | | Insurance policy end date | 2019-08-31 | | Total amount of commissions paid to insurance broker | USD $6,014 | | Total amount of fees paid to insurance company | USD $2,945 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | No | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $60,143 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,014 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 2945 | | Additional information about fees paid to insurance broker | FEES |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | VDT962179 |
| Policy instance | 2 |
| Insurance contract or identification number | VDT962179 | | Number of Individuals Covered | 396 | | Insurance policy start date | 2018-09-01 | | Insurance policy end date | 2019-08-31 | | Total amount of commissions paid to insurance broker | USD $11,857 | | Total amount of fees paid to insurance company | USD $5,893 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | No | | Temporary Disability Insurance Welfare Benefit | No | | 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 $118,565 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $11,857 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 5893 | | Additional information about fees paid to insurance broker | FEES |
|
| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
| Policy contract number | 3340055 |
| Policy instance | 1 |
| Insurance contract or identification number | 3340055 | | Number of Individuals Covered | 1048 | | Insurance policy start date | 2018-09-01 | | Insurance policy end date | 2019-08-31 | | Total amount of commissions paid to insurance broker | USD $149,955 | | Total amount of fees paid to insurance company | USD $54,213 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | Yes | | 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 | | Other welfare benefits provided | PREPAID DENTAL | | 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 $1,169,290 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $149,955 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 54213 | | Additional information about fees paid to insurance broker | FEES |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | FLX967456 |
| Policy instance | 4 |
| Insurance contract or identification number | FLX967456 | | Number of Individuals Covered | 978 | | Insurance policy start date | 2018-09-01 | | Insurance policy end date | 2019-08-31 | | Total amount of commissions paid to insurance broker | USD $1,348 | | Total amount of fees paid to insurance company | USD $604 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | 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 $12,110 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,348 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 604 | | Additional information about fees paid to insurance broker | FEES |
|
| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
| Policy contract number | 3340055 |
| Policy instance | 1 |
| Insurance contract or identification number | 3340055 | | Number of Individuals Covered | 1080 | | Insurance policy start date | 2017-09-01 | | Insurance policy end date | 2018-08-31 | | Total amount of commissions paid to insurance broker | USD $139,160 | | Total amount of fees paid to insurance company | USD $66,861 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | Yes | | 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 | | Other welfare benefits provided | PREPAID DENTAL | | 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 $1,070,375 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | OK 968968 |
| Policy instance | 5 |
| Insurance contract or identification number | OK 968968 | | Number of Individuals Covered | 936 | | Insurance policy start date | 2017-09-01 | | Insurance policy end date | 2018-08-31 | | Total amount of commissions paid to insurance broker | USD $473 | | Total amount of fees paid to insurance company | USD $158 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | AD&D | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $3,148 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | VDT962179 |
| Policy instance | 2 |
| Insurance contract or identification number | VDT962179 | | Number of Individuals Covered | 296 | | Insurance policy start date | 2017-09-01 | | Insurance policy end date | 2018-08-31 | | Total amount of commissions paid to insurance broker | USD $8,895 | | Total amount of fees paid to insurance company | USD $4,448 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | No | | Temporary Disability Insurance Welfare Benefit | No | | 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 $88,951 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | VDT962178 |
| Policy instance | 3 |
| Insurance contract or identification number | VDT962178 | | Number of Individuals Covered | 305 | | Insurance policy start date | 2017-09-01 | | Insurance policy end date | 2018-08-31 | | Total amount of commissions paid to insurance broker | USD $4,048 | | Total amount of fees paid to insurance company | USD $2,024 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | No | | Temporary Disability Insurance Welfare Benefit | Yes | | 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 $40,480 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | FLX967456 |
| Policy instance | 4 |
| Insurance contract or identification number | FLX967456 | | Number of Individuals Covered | 936 | | Insurance policy start date | 2017-09-01 | | Insurance policy end date | 2018-08-31 | | Total amount of commissions paid to insurance broker | USD $1,286 | | Total amount of fees paid to insurance company | USD $538 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | 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 $10,767 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | FLX967457 |
| Policy instance | 6 |
| Insurance contract or identification number | FLX967457 | | Number of Individuals Covered | 480 | | Insurance policy start date | 2017-09-01 | | Insurance policy end date | 2018-08-30 | | Total amount of commissions paid to insurance broker | USD $13,867 | | Total amount of fees paid to insurance company | USD $6,933 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | VOLUNTARY SUPPLEMENTAL LIFE AND DEPENDENT LIFE | | 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 $138,661 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 ) |
| Policy contract number | 50012734 |
| Policy instance | 2 |
| Insurance contract or identification number | 50012734 | | Number of Individuals Covered | 154 | | Insurance policy start date | 2015-09-01 | | Insurance policy end date | 2016-08-31 | | Total amount of commissions paid to insurance broker | USD $15,097 | | Total amount of fees paid to insurance company | USD $8,185 | | 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 | No | | Temporary Disability Insurance Welfare Benefit | No | | 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 $48,769 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $13,061 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 8185 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker name | BLOOM HEALTH INSURANCE AGENCY LLC |
|
| USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 ) |
| Policy contract number | 50012734 |
| Policy instance | 1 |
| Insurance contract or identification number | 50012734 | | Number of Individuals Covered | 813 | | Insurance policy start date | 2015-09-01 | | Insurance policy end date | 2016-08-31 | | Total amount of commissions paid to insurance broker | USD $2,623 | | Total amount of fees paid to insurance company | USD $1,482 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | 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 $14,321 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,048 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 1482 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker name | BLOOM HEALTH INSURANCE AGENCY LLC |
|
| HORIZON HEALTHCARE SERVICES, INC. (National Association of Insurance Commissioners NAIC id number: 55069 ) |
| Policy contract number | 86607 |
| Policy instance | 5 |
| Insurance contract or identification number | 86607 | | Number of Individuals Covered | 517 | | Insurance policy start date | 2015-09-01 | | Insurance policy end date | 2016-08-31 | | Total amount of commissions paid to insurance broker | USD $92,203 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $3,459,719 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $92,203 | | Insurance broker organization code? | 3 | | Insurance broker name | GROUP HEALTH SOLUTIONS INC |
|
| HORIZON INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 14690 ) |
| Policy contract number | 86608 |
| Policy instance | 8 |
| Insurance contract or identification number | 86608 | | Number of Individuals Covered | 454 | | Insurance policy start date | 2015-09-01 | | Insurance policy end date | 2016-08-30 | | Total amount of commissions paid to insurance broker | USD $4,563 | | 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 $45,233 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,563 | | Insurance broker organization code? | 3 | | Insurance broker name | GROUP HEALTH SOLUTIONS INC |
|
| HORIZON HEALTHCARE SERVICES, INC. (National Association of Insurance Commissioners NAIC id number: 55069 ) |
| Policy contract number | 86609 |
| Policy instance | 7 |
| Insurance contract or identification number | 86609 | | Number of Individuals Covered | 543 | | Insurance policy start date | 2015-09-01 | | Insurance policy end date | 2016-08-30 | | Total amount of commissions paid to insurance broker | USD $8,531 | | 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 | 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 | | Welfare Benefit Premiums Paid to Carrier | USD $310,372 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,531 | | Insurance broker organization code? | 3 | | Insurance broker name | GROUP HEALTH SOLUTIONS INC. |
|
| HORIZON HEALTHCARE SERVICES, INC. (National Association of Insurance Commissioners NAIC id number: 55069 ) |
| Policy contract number | 86607 |
| Policy instance | 6 |
| Insurance contract or identification number | 86607 | | Number of Individuals Covered | 333 | | Insurance policy start date | 2015-09-01 | | Insurance policy end date | 2016-08-31 | | Total amount of commissions paid to insurance broker | USD $12,706 | | 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 | 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 $683,876 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $12,706 | | Insurance broker organization code? | 3 | | Insurance broker name | GROUP HEALTH SOLUTIONS INC. |
|
| USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 ) |
| Policy contract number | 50012734 |
| Policy instance | 3 |
| Insurance contract or identification number | 50012734 | | Number of Individuals Covered | 172 | | Insurance policy start date | 2015-09-01 | | Insurance policy end date | 2016-08-31 | | Total amount of commissions paid to insurance broker | USD $5,140 | | Total amount of fees paid to insurance company | USD $2,545 | | 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 | No | | Temporary Disability Insurance Welfare Benefit | Yes | | 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 $7,685 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,383 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 2545 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker name | BOOM HEALTH INSURANCE AGENCY LLC |
|
| USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 ) |
| Policy contract number | 50012734 |
| Policy instance | 4 |
| Insurance contract or identification number | 50012734 | | Number of Individuals Covered | 452 | | Insurance policy start date | 2015-09-01 | | Insurance policy end date | 2016-08-31 | | Total amount of commissions paid to insurance broker | USD $13,039 | | Total amount of fees paid to insurance company | USD $6,954 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | SUPPLEMENTAL LIFE AND DEPENDENT LIFE | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $19,993 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $10,431 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 6954 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker name | BLOOM HEALTH INSURANCE AGENCY LLC |
|
| HORIZON INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 14690 ) |
| Policy contract number | 86608 |
| Policy instance | 8 |
| Insurance contract or identification number | 86608 | | Number of Individuals Covered | 444 | | Insurance policy start date | 2014-09-01 | | Insurance policy end date | 2015-08-30 | | Total amount of commissions paid to insurance broker | USD $4,322 | | 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 $43,504 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,322 | | Insurance broker organization code? | 3 | | Insurance broker name | GROUP HEALTH SOLUTIONS INC |
|
| HORIZON HEALTHCARE SERVICES, INC. (National Association of Insurance Commissioners NAIC id number: 55069 ) |
| Policy contract number | 86607 |
| Policy instance | 5 |
| Insurance contract or identification number | 86607 | | Number of Individuals Covered | 519 | | Insurance policy start date | 2014-09-01 | | Insurance policy end date | 2015-08-31 | | Total amount of commissions paid to insurance broker | USD $92,494 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $3,271,807 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $92,494 | | Insurance broker organization code? | 3 | | Insurance broker name | GROUP HEALTH SOLUTIONS INC |
|
| USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 ) |
| Policy contract number | 50012734 |
| Policy instance | 2 |
| Insurance contract or identification number | 50012734 | | Number of Individuals Covered | 273 | | Insurance policy start date | 2014-09-01 | | Insurance policy end date | 2015-08-31 | | Total amount of commissions paid to insurance broker | USD $4,643 | | Total amount of fees paid to insurance company | USD $3,682 | | 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 | No | | Temporary Disability Insurance Welfare Benefit | No | | 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 $64,269 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,643 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 3682 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker name | HORIZON INSURANCE COMPANY |
|
| HORIZON HEALTHCARE SERVICES, INC. (National Association of Insurance Commissioners NAIC id number: 55069 ) |
| Policy contract number | 86609 |
| Policy instance | 7 |
| Insurance contract or identification number | 86609 | | Number of Individuals Covered | 527 | | Insurance policy start date | 2014-09-01 | | Insurance policy end date | 2015-08-30 | | Total amount of commissions paid to insurance broker | USD $8,215 | | 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 | 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 | | Welfare Benefit Premiums Paid to Carrier | USD $297,285 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,215 | | Insurance broker organization code? | 3 | | Insurance broker name | GROUP HEALTH SOLUTIONS INC. |
|
| USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 ) |
| Policy contract number | 50012734 |
| Policy instance | 1 |
| Insurance contract or identification number | 50012734 | | Number of Individuals Covered | 617 | | Insurance policy start date | 2014-09-01 | | Insurance policy end date | 2015-08-31 | | Total amount of commissions paid to insurance broker | USD $750 | | Total amount of fees paid to insurance company | USD $619 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | 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 $8,445 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $750 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 619 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker name | HORIZON INSURANCE COMPANY |
|
| USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 ) |
| Policy contract number | 50012734 |
| Policy instance | 3 |
| Insurance contract or identification number | 50012734 | | Number of Individuals Covered | 301 | | Insurance policy start date | 2014-09-01 | | Insurance policy end date | 2015-08-31 | | Total amount of commissions paid to insurance broker | USD $2,253 | | Total amount of fees paid to insurance company | USD $1,860 | | 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 | No | | Temporary Disability Insurance Welfare Benefit | Yes | | 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 $25,367 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,253 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 1860 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker name | HORIZON INSURANCE COMPANY |
|
| HORIZON HEALTHCARE SERVICES, INC. (National Association of Insurance Commissioners NAIC id number: 55069 ) |
| Policy contract number | 86607 |
| Policy instance | 6 |
| Insurance contract or identification number | 86607 | | Number of Individuals Covered | 519 | | Insurance policy start date | 2014-09-01 | | Insurance policy end date | 2015-08-31 | | Total amount of commissions paid to insurance broker | USD $12,140 | | 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 | 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 $534,785 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $12,140 | | Insurance broker organization code? | 3 | | Insurance broker name | GROUP HEALTH SOLUTIONS INC. |
|
| USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 ) |
| Policy contract number | 50012734 |
| Policy instance | 4 |
| Insurance contract or identification number | 50012734 | | Number of Individuals Covered | 516 | | Insurance policy start date | 2014-09-01 | | Insurance policy end date | 2015-08-31 | | Total amount of commissions paid to insurance broker | USD $11,039 | | Total amount of fees paid to insurance company | USD $7,359 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | SUPPLEMENTAL LIFE AND DEPENDENT LIFE | | 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 $73,595 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $11,039 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 7359 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker name | HORIZON INSURANCE COMPANY |
|
| HORIZON HEALTHCARE SERVICES, INC. (National Association of Insurance Commissioners NAIC id number: 55069 ) |
| Policy contract number | 86463 |
| Policy instance | 6 |
| Insurance contract or identification number | 86463 | | Number of Individuals Covered | 415 | | Insurance policy start date | 2013-09-01 | | Insurance policy end date | 2014-08-31 | | Total amount of commissions paid to insurance broker | USD $14,084 | | 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 | 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 $483,527 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $14,084 | | Insurance broker organization code? | 3 | | Insurance broker name | GROUP HEALTH SOLUTIONS, INC |
|
| HORIZON HEALTHCARE SERVICES, INC. (National Association of Insurance Commissioners NAIC id number: 55069 ) |
| Policy contract number | 86464 |
| Policy instance | 7 |
| Insurance contract or identification number | 86464 | | Number of Individuals Covered | 70 | | Insurance policy start date | 2013-09-01 | | Insurance policy end date | 2014-08-31 | | Total amount of commissions paid to insurance broker | USD $2,393 | | 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 | 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 $82,348 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,393 | | Insurance broker organization code? | 3 | | Insurance broker name | GROUP HEALTH SOLUTIONS, INC |
|
| HORIZON HEALTHCARE SERVICES, INC. (National Association of Insurance Commissioners NAIC id number: 55069 ) |
| Policy contract number | 86465 |
| Policy instance | 9 |
| Insurance contract or identification number | 86465 | | Number of Individuals Covered | 453 | | Insurance policy start date | 2013-09-01 | | Insurance policy end date | 2014-08-31 | | Total amount of commissions paid to insurance broker | USD $7,470 | | 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 | 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 | | Welfare Benefit Premiums Paid to Carrier | USD $258,550 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,470 | | Insurance broker organization code? | 3 | | Insurance broker name | GROUP HEALTH SOLUTIONS, INC |
|
| HORIZON HEALTHCARE SERVICES, INC. (National Association of Insurance Commissioners NAIC id number: 55069 ) |
| Policy contract number | 86463 |
| Policy instance | 5 |
| Insurance contract or identification number | 86463 | | Number of Individuals Covered | 415 | | Insurance policy start date | 2013-09-01 | | Insurance policy end date | 2014-08-30 | | Total amount of commissions paid to insurance broker | USD $73,895 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $2,601,099 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $73,895 | | Insurance broker organization code? | 3 | | Insurance broker name | GROUP HEALTH SOLUTIONS, INC |
|
| USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 ) |
| Policy contract number | 50012734 |
| Policy instance | 4 |
| Insurance contract or identification number | 50012734 | | Number of Individuals Covered | 303 | | Insurance policy start date | 2013-09-01 | | Insurance policy end date | 2014-08-30 | | Total amount of commissions paid to insurance broker | USD $11,257 | | Total amount of fees paid to insurance company | USD $7,504 | | 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 | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | SUPPLEMENTAL AND DEPENDENT LIFE | | 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 $75,044 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $11,257 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 7504 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | | Insurance broker name | HORIZON INSURANCE COMPANY |
|
| USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 ) |
| Policy contract number | 50012734 |
| Policy instance | 3 |
| Insurance contract or identification number | 50012734 | | Number of Individuals Covered | 161 | | Insurance policy start date | 2013-09-01 | | Insurance policy end date | 2014-08-31 | | Total amount of commissions paid to insurance broker | USD $2,407 | | Total amount of fees paid to insurance company | USD $2,082 | | 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 | No | | Temporary Disability Insurance Welfare Benefit | Yes | | 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 $29,055 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,407 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 2082 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | | Insurance broker name | HORIZON INSURANCE COMPANY |
|
| USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 ) |
| Policy contract number | 50012734 |
| Policy instance | 2 |
| Insurance contract or identification number | 50012734 | | Number of Individuals Covered | 155 | | Insurance policy start date | 2013-09-01 | | Insurance policy end date | 2014-08-31 | | Total amount of commissions paid to insurance broker | USD $4,661 | | Total amount of fees paid to insurance company | USD $3,727 | | 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 | No | | Temporary Disability Insurance Welfare Benefit | No | | 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 $66,096 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,661 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 3727 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | | Insurance broker name | HORIZON INSURANCE COMPANY |
|
| USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 ) |
| Policy contract number | 50012734 |
| Policy instance | 1 |
| Insurance contract or identification number | 50012734 | | Number of Individuals Covered | 468 | | Insurance policy start date | 2013-09-01 | | Insurance policy end date | 2014-08-31 | | Total amount of commissions paid to insurance broker | USD $788 | | Total amount of fees paid to insurance company | USD $686 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | 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 $9,576 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $788 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 686 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | | Insurance broker name | HORIZON INSURANCE COMPANY |
|
| HORIZON HEALTHCARE SERVICES, INC. (National Association of Insurance Commissioners NAIC id number: 55069 ) |
| Policy contract number | 86478 |
| Policy instance | 10 |
| Insurance contract or identification number | 86478 | | Number of Individuals Covered | 453 | | Insurance policy start date | 2013-09-01 | | Insurance policy end date | 2014-08-31 | | Total amount of commissions paid to insurance broker | USD $7,470 | | 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 | 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 | | Welfare Benefit Premiums Paid to Carrier | USD $24,359 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,470 | | Insurance broker organization code? | 3 | | Insurance broker name | GROUP HEALTH SOLUTIONS, INC |
|
| HORIZON HEALTHCARE SERVICES, INC. (National Association of Insurance Commissioners NAIC id number: 55069 ) |
| Policy contract number | 86464 |
| Policy instance | 8 |
| Insurance contract or identification number | 86464 | | Number of Individuals Covered | 70 | | Insurance policy start date | 2013-09-01 | | Insurance policy end date | 2014-08-31 | | Total amount of commissions paid to insurance broker | USD $20,008 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $695,760 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $20,008 | | Insurance broker organization code? | 3 | | Insurance broker name | GROUP HEALTH SOLUTIONS, INC |
|
| USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 ) |
| Policy contract number | 50012734 ET AL |
| Policy instance | 2 |
| Insurance contract or identification number | 50012734 ET AL | | Number of Individuals Covered | 546 | | Insurance policy start date | 2012-09-01 | | Insurance policy end date | 2013-08-31 | | Total amount of commissions paid to insurance broker | USD $21,578 | | Total amount of fees paid to insurance company | USD $16,120 | | 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 | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | 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 $209,310 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $21,578 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 16120 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | | Insurance broker name | RAYANT INSURANCE AGENCY |
|
| HORIZON HEALTHCARE SERVICES, INC. (National Association of Insurance Commissioners NAIC id number: 55069 ) |
| Policy contract number | 86872/86873 |
| Policy instance | 1 |
| Insurance contract or identification number | 86872/86873 | | Number of Individuals Covered | 269 | | Insurance policy start date | 2012-09-01 | | Insurance policy end date | 2013-08-31 | | Total amount of commissions paid to insurance broker | USD $110,698 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | 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 | | Welfare Benefit Premiums Paid to Carrier | USD $3,839,737 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $110,698 | | Insurance broker organization code? | 3 | | Insurance broker name | GROUP HEALTH SOLUTIONS, INC. |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AGH3 |
| Policy instance | 2 |
| Insurance contract or identification number | G000AGH3 | | Number of Individuals Covered | 487 | | Insurance policy start date | 2011-09-01 | | Insurance policy end date | 2012-08-31 | | Total amount of commissions paid to insurance broker | USD $37,558 | | 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 $218,365 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HORIZON HEALTHCARE SERVICES, INC. (National Association of Insurance Commissioners NAIC id number: 55069 ) |
| Policy contract number | 86872 |
| Policy instance | 1 |
| Insurance contract or identification number | 86872 | | Number of Individuals Covered | 580 | | Insurance policy start date | 2011-09-01 | | Insurance policy end date | 2012-08-31 | | Total amount of commissions paid to insurance broker | USD $117,648 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | 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 | | Welfare Benefit Premiums Paid to Carrier | USD $2,653,765 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HORIZON HEALTHCARE SERVICES, INC. (National Association of Insurance Commissioners NAIC id number: 55069 ) |
| Policy contract number | 86872 |
| Policy instance | 2 |
| Insurance contract or identification number | 86872 | | Number of Individuals Covered | 580 | | Insurance policy start date | 2011-09-01 | | Insurance policy end date | 2012-08-31 | | Total amount of commissions paid to insurance broker | USD $16,924 | | Total amount of fees paid to insurance company | USD $0 | | Were dividends or retroactive rate refunds paid as a credit? | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $331,771 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HORIZON HEALTHCARE SERVICES, INC. (National Association of Insurance Commissioners NAIC id number: 55069 ) |
| Policy contract number | 86872 |
| Policy instance | 1 |
| Insurance contract or identification number | 86872 | | Number of Individuals Covered | 580 | | Insurance policy start date | 2011-09-01 | | Insurance policy end date | 2012-08-31 | | Total amount of commissions paid to insurance broker | USD $93,665 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Were dividends or retroactive rate refunds paid as a credit? | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,972,379 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AGH3 |
| Policy instance | 7 |
| Insurance contract or identification number | G000AGH3 | | Number of Individuals Covered | 487 | | Insurance policy start date | 2011-09-01 | | Insurance policy end date | 2012-08-31 | | Total amount of commissions paid to insurance broker | USD $1,800 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $11,997 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AGH3 |
| Policy instance | 6 |
| Insurance contract or identification number | G000AGH3 | | Number of Individuals Covered | 276 | | Insurance policy start date | 2011-09-01 | | Insurance policy end date | 2012-08-31 | | Total amount of commissions paid to insurance broker | USD $6,774 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $45,179 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AGH3 |
| Policy instance | 5 |
| Insurance contract or identification number | G000AGH3 | | Number of Individuals Covered | 240 | | Insurance policy start date | 2011-09-01 | | Insurance policy end date | 2012-08-31 | | Total amount of commissions paid to insurance broker | USD $9,767 | | Total amount of fees paid to insurance company | USD $0 | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | VOL LTD | | Welfare Benefit Premiums Paid to Carrier | USD $65,117 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AGH3 |
| Policy instance | 4 |
| Insurance contract or identification number | G000AGH3 | | Number of Individuals Covered | 265 | | Insurance policy start date | 2011-09-01 | | Insurance policy end date | 2012-08-31 | | Total amount of commissions paid to insurance broker | USD $19,214 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $96,072 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HORIZON HEALTHCARE SERVICES, INC. (National Association of Insurance Commissioners NAIC id number: 55069 ) |
| Policy contract number | 086872 |
| Policy instance | 3 |
| Insurance contract or identification number | 086872 | | Number of Individuals Covered | 577 | | Insurance policy start date | 2011-09-01 | | Insurance policy end date | 2012-08-31 | | Total amount of commissions paid to insurance broker | USD $7,059 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $349,615 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HORIZON HEALTHCARE SERVICES, INC. (National Association of Insurance Commissioners NAIC id number: 55069 ) |
| Policy contract number | 086872 |
| Policy instance | 1 |
| Insurance contract or identification number | 086872 | | Number of Individuals Covered | 576 | | Insurance policy start date | 2010-09-01 | | Insurance policy end date | 2011-08-31 | | Total amount of commissions paid to insurance broker | USD $6,894 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $341,761 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AGH3 |
| Policy instance | 6 |
| Insurance contract or identification number | G000AGH3 | | Number of Individuals Covered | 335 | | Insurance policy start date | 2010-09-01 | | Insurance policy end date | 2011-08-31 | | Total amount of commissions paid to insurance broker | USD $26,943 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $118,377 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AGH3 |
| Policy instance | 5 |
| Insurance contract or identification number | G000AGH3 | | Number of Individuals Covered | 298 | | Insurance policy start date | 2010-09-01 | | Insurance policy end date | 2011-08-31 | | Total amount of commissions paid to insurance broker | USD $8,260 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $46,157 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AGH3 |
| Policy instance | 4 |
| Insurance contract or identification number | G000AGH3 | | Number of Individuals Covered | 611 | | Insurance policy start date | 2010-09-01 | | Insurance policy end date | 2011-08-31 | | Total amount of commissions paid to insurance broker | USD $2,287 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $13,474 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AGH3 |
| Policy instance | 3 |
| Insurance contract or identification number | G000AGH3 | | Number of Individuals Covered | 278 | | Insurance policy start date | 2010-09-01 | | Insurance policy end date | 2011-08-31 | | Total amount of commissions paid to insurance broker | USD $12,699 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $70,379 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HORIZON HEALTHCARE SERVICES, INC. (National Association of Insurance Commissioners NAIC id number: 55069 ) |
| Policy contract number | 86872 |
| Policy instance | 2 |
| Insurance contract or identification number | 86872 | | Number of Individuals Covered | 592 | | Insurance policy start date | 2010-09-01 | | Insurance policy end date | 2011-08-31 | | Total amount of commissions paid to insurance broker | USD $160,800 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $4,641,406 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
