CLEVELAND BROTHERS EQUIPMENT CO INC has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan CLEVELAND BROTHERS EQUIPMENT CO.,INC. HEALTH CARE PLAN
401k plan membership statisitcs for CLEVELAND BROTHERS EQUIPMENT CO.,INC. HEALTH CARE PLAN
| Measure | Date | Value |
|---|
| 2023: CLEVELAND BROTHERS EQUIPMENT CO.,INC. HEALTH CARE PLAN 2023 401k membership |
|---|
| Total participants, beginning-of-year | 2023-01-01 | 1,502 |
| Total number of active participants reported on line 7a of the Form 5500 | 2023-01-01 | 1,525 |
| Number of retired or separated participants receiving benefits | 2023-01-01 | 19 |
| Number of other retired or separated participants entitled to future benefits | 2023-01-01 | 0 |
| Total of all active and inactive participants | 2023-01-01 | 1,544 |
| Number of employers contributing to the scheme | 2023-01-01 | 0 |
| 2022: CLEVELAND BROTHERS EQUIPMENT CO.,INC. HEALTH CARE PLAN 2022 401k membership |
|---|
| Total participants, beginning-of-year | 2022-01-01 | 1,700 |
| Total number of active participants reported on line 7a of the Form 5500 | 2022-01-01 | 1,483 |
| Number of retired or separated participants receiving benefits | 2022-01-01 | 19 |
| Number of other retired or separated participants entitled to future benefits | 2022-01-01 | 0 |
| Total of all active and inactive participants | 2022-01-01 | 1,502 |
| 2021: CLEVELAND BROTHERS EQUIPMENT CO.,INC. HEALTH CARE PLAN 2021 401k membership |
|---|
| Total participants, beginning-of-year | 2021-01-01 | 1,682 |
| Total number of active participants reported on line 7a of the Form 5500 | 2021-01-01 | 1,513 |
| Number of retired or separated participants receiving benefits | 2021-01-01 | 187 |
| Number of other retired or separated participants entitled to future benefits | 2021-01-01 | 0 |
| Total of all active and inactive participants | 2021-01-01 | 1,700 |
| 2020: CLEVELAND BROTHERS EQUIPMENT CO.,INC. HEALTH CARE PLAN 2020 401k membership |
|---|
| Total participants, beginning-of-year | 2020-01-01 | 1,739 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-01-01 | 1,682 |
| Number of retired or separated participants receiving benefits | 2020-01-01 | 165 |
| Number of other retired or separated participants entitled to future benefits | 2020-01-01 | 0 |
| Total of all active and inactive participants | 2020-01-01 | 1,847 |
| 2019: CLEVELAND BROTHERS EQUIPMENT CO.,INC. HEALTH CARE PLAN 2019 401k membership |
|---|
| Total participants, beginning-of-year | 2019-01-01 | 1,713 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-01-01 | 1,659 |
| Number of retired or separated participants receiving benefits | 2019-01-01 | 80 |
| Total of all active and inactive participants | 2019-01-01 | 1,739 |
| 2018: CLEVELAND BROTHERS EQUIPMENT CO.,INC. HEALTH CARE PLAN 2018 401k membership |
|---|
| Total participants, beginning-of-year | 2018-01-01 | 1,591 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-01-01 | 1,631 |
| Number of retired or separated participants receiving benefits | 2018-01-01 | 82 |
| Total of all active and inactive participants | 2018-01-01 | 1,713 |
| Total participants | 2018-01-01 | 1,713 |
| 2017: CLEVELAND BROTHERS EQUIPMENT CO.,INC. HEALTH CARE PLAN 2017 401k membership |
|---|
| Total participants, beginning-of-year | 2017-01-01 | 1,297 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-01-01 | 1,507 |
| Number of retired or separated participants receiving benefits | 2017-01-01 | 84 |
| Total of all active and inactive participants | 2017-01-01 | 1,591 |
| Total participants | 2017-01-01 | 1,591 |
| 2016: CLEVELAND BROTHERS EQUIPMENT CO.,INC. HEALTH CARE PLAN 2016 401k membership |
|---|
| Total participants, beginning-of-year | 2016-01-01 | 1,378 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-01-01 | 1,212 |
| Number of retired or separated participants receiving benefits | 2016-01-01 | 85 |
| Total of all active and inactive participants | 2016-01-01 | 1,297 |
| Total participants | 2016-01-01 | 1,297 |
| 2015: CLEVELAND BROTHERS EQUIPMENT CO.,INC. HEALTH CARE PLAN 2015 401k membership |
|---|
| Total participants, beginning-of-year | 2015-01-01 | 1,516 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-01-01 | 1,378 |
| Number of retired or separated participants receiving benefits | 2015-01-01 | 93 |
| Total of all active and inactive participants | 2015-01-01 | 1,471 |
| Total participants | 2015-01-01 | 1,471 |
| 2014: CLEVELAND BROTHERS EQUIPMENT CO.,INC. HEALTH CARE PLAN 2014 401k membership |
|---|
| Total participants, beginning-of-year | 2014-11-01 | 1,749 |
| Total number of active participants reported on line 7a of the Form 5500 | 2014-11-01 | 1,423 |
| Number of retired or separated participants receiving benefits | 2014-11-01 | 93 |
| Total of all active and inactive participants | 2014-11-01 | 1,516 |
| Total participants | 2014-11-01 | 1,516 |
| 2013: CLEVELAND BROTHERS EQUIPMENT CO.,INC. HEALTH CARE PLAN 2013 401k membership |
|---|
| Total participants, beginning-of-year | 2013-11-01 | 1,671 |
| Total number of active participants reported on line 7a of the Form 5500 | 2013-11-01 | 1,654 |
| Number of retired or separated participants receiving benefits | 2013-11-01 | 95 |
| Total of all active and inactive participants | 2013-11-01 | 1,749 |
| Total participants | 2013-11-01 | 1,749 |
| 2012: CLEVELAND BROTHERS EQUIPMENT CO.,INC. HEALTH CARE PLAN 2012 401k membership |
|---|
| Total participants, beginning-of-year | 2012-11-01 | 1,428 |
| Total number of active participants reported on line 7a of the Form 5500 | 2012-11-01 | 1,574 |
| Number of retired or separated participants receiving benefits | 2012-11-01 | 97 |
| Total of all active and inactive participants | 2012-11-01 | 1,671 |
| Total participants | 2012-11-01 | 1,671 |
| 2011: CLEVELAND BROTHERS EQUIPMENT CO.,INC. HEALTH CARE PLAN 2011 401k membership |
|---|
| Total participants, beginning-of-year | 2011-11-01 | 1,522 |
| Total number of active participants reported on line 7a of the Form 5500 | 2011-11-01 | 1,330 |
| Number of retired or separated participants receiving benefits | 2011-11-01 | 98 |
| Total of all active and inactive participants | 2011-11-01 | 1,428 |
| Total participants | 2011-11-01 | 1,428 |
| 2010: CLEVELAND BROTHERS EQUIPMENT CO.,INC. HEALTH CARE PLAN 2010 401k membership |
|---|
| Total participants, beginning-of-year | 2010-11-01 | 1,385 |
| Total number of active participants reported on line 7a of the Form 5500 | 2010-11-01 | 1,421 |
| Number of retired or separated participants receiving benefits | 2010-11-01 | 101 |
| Total of all active and inactive participants | 2010-11-01 | 1,522 |
| Total participants | 2010-11-01 | 1,522 |
| 2009: CLEVELAND BROTHERS EQUIPMENT CO.,INC. HEALTH CARE PLAN 2009 401k membership |
|---|
| Total participants, beginning-of-year | 2009-11-01 | 1,576 |
| Total number of active participants reported on line 7a of the Form 5500 | 2009-11-01 | 1,229 |
| Number of retired or separated participants receiving benefits | 2009-11-01 | 156 |
| Total of all active and inactive participants | 2009-11-01 | 1,385 |
| 2023: CLEVELAND BROTHERS EQUIPMENT CO.,INC. HEALTH CARE PLAN 2023 form 5500 responses |
|---|
| 2023-01-01 | Type of plan entity | Single employer plan |
| 2023-01-01 | Plan is a collectively bargained plan | Yes |
| 2023-01-01 | Plan funding arrangement – Insurance | Yes |
| 2023-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2023-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2023-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2022: CLEVELAND BROTHERS EQUIPMENT CO.,INC. HEALTH CARE PLAN 2022 form 5500 responses |
|---|
| 2022-01-01 | Type of plan entity | Single employer plan |
| 2022-01-01 | Submission has been amended | No |
| 2022-01-01 | This submission is the final filing | No |
| 2022-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2022-01-01 | Plan is a collectively bargained plan | Yes |
| 2022-01-01 | Plan funding arrangement – Insurance | Yes |
| 2022-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2022-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2022-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2021: CLEVELAND BROTHERS EQUIPMENT CO.,INC. HEALTH CARE PLAN 2021 form 5500 responses |
|---|
| 2021-01-01 | Type of plan entity | Single employer plan |
| 2021-01-01 | Submission has been amended | No |
| 2021-01-01 | This submission is the final filing | No |
| 2021-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2021-01-01 | Plan is a collectively bargained plan | Yes |
| 2021-01-01 | Plan funding arrangement – Insurance | Yes |
| 2021-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2021-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2021-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2020: CLEVELAND BROTHERS EQUIPMENT CO.,INC. HEALTH CARE PLAN 2020 form 5500 responses |
|---|
| 2020-01-01 | Type of plan entity | Single employer plan |
| 2020-01-01 | Submission has been amended | No |
| 2020-01-01 | This submission is the final filing | No |
| 2020-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2020-01-01 | Plan is a collectively bargained plan | Yes |
| 2020-01-01 | Plan funding arrangement – Insurance | Yes |
| 2020-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2020-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2020-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2019: CLEVELAND BROTHERS EQUIPMENT CO.,INC. HEALTH CARE PLAN 2019 form 5500 responses |
|---|
| 2019-01-01 | Type of plan entity | Single employer plan |
| 2019-01-01 | Plan funding arrangement – Insurance | Yes |
| 2019-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2019-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2019-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2018: CLEVELAND BROTHERS EQUIPMENT CO.,INC. HEALTH CARE PLAN 2018 form 5500 responses |
|---|
| 2018-01-01 | Type of plan entity | Single employer plan |
| 2018-01-01 | Plan funding arrangement – Insurance | Yes |
| 2018-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2018-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2018-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2017: CLEVELAND BROTHERS EQUIPMENT CO.,INC. HEALTH CARE PLAN 2017 form 5500 responses |
|---|
| 2017-01-01 | Type of plan entity | Single employer plan |
| 2017-01-01 | Plan funding arrangement – Insurance | Yes |
| 2017-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2017-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2017-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2016: CLEVELAND BROTHERS EQUIPMENT CO.,INC. HEALTH CARE PLAN 2016 form 5500 responses |
|---|
| 2016-01-01 | Type of plan entity | Single employer plan |
| 2016-01-01 | Plan funding arrangement – Insurance | Yes |
| 2016-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2016-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2016-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2015: CLEVELAND BROTHERS EQUIPMENT CO.,INC. HEALTH CARE PLAN 2015 form 5500 responses |
|---|
| 2015-01-01 | Type of plan entity | Single employer plan |
| 2015-01-01 | Plan funding arrangement – Insurance | Yes |
| 2015-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2015-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2015-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2014: CLEVELAND BROTHERS EQUIPMENT CO.,INC. HEALTH CARE PLAN 2014 form 5500 responses |
|---|
| 2014-11-01 | Type of plan entity | Single employer plan |
| 2014-11-01 | This return/report is a short plan year return/report (less than 12 months) | Yes |
| 2014-11-01 | Plan funding arrangement – Insurance | Yes |
| 2014-11-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2014-11-01 | Plan benefit arrangement – Insurance | Yes |
| 2014-11-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2013: CLEVELAND BROTHERS EQUIPMENT CO.,INC. HEALTH CARE PLAN 2013 form 5500 responses |
|---|
| 2013-11-01 | Type of plan entity | Single employer plan |
| 2013-11-01 | Plan funding arrangement – Insurance | Yes |
| 2013-11-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2013-11-01 | Plan benefit arrangement – Insurance | Yes |
| 2013-11-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2012: CLEVELAND BROTHERS EQUIPMENT CO.,INC. HEALTH CARE PLAN 2012 form 5500 responses |
|---|
| 2012-11-01 | Type of plan entity | Single employer plan |
| 2012-11-01 | Plan funding arrangement – Insurance | Yes |
| 2012-11-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2012-11-01 | Plan benefit arrangement – Insurance | Yes |
| 2012-11-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2011: CLEVELAND BROTHERS EQUIPMENT CO.,INC. HEALTH CARE PLAN 2011 form 5500 responses |
|---|
| 2011-11-01 | Type of plan entity | Single employer plan |
| 2011-11-01 | Plan funding arrangement – Insurance | Yes |
| 2011-11-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2011-11-01 | Plan benefit arrangement – Insurance | Yes |
| 2011-11-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2010: CLEVELAND BROTHERS EQUIPMENT CO.,INC. HEALTH CARE PLAN 2010 form 5500 responses |
|---|
| 2010-11-01 | Type of plan entity | Single employer plan |
| 2010-11-01 | Plan funding arrangement – Insurance | Yes |
| 2010-11-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2010-11-01 | Plan benefit arrangement – Insurance | Yes |
| 2010-11-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2009: CLEVELAND BROTHERS EQUIPMENT CO.,INC. HEALTH CARE PLAN 2009 form 5500 responses |
|---|
| 2009-11-01 | Type of plan entity | Single employer plan |
| 2009-11-01 | This submission is the final filing | No |
| 2009-11-01 | Plan funding arrangement – Insurance | Yes |
| 2009-11-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2009-11-01 | Plan benefit arrangement – Insurance | Yes |
| 2009-11-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| SYMETRA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68608 ) |
| Policy contract number | 01-017605-00 |
| Policy instance | 4 |
| Insurance contract or identification number | 01-017605-00 | | Number of Individuals Covered | 1525 | | Insurance policy start date | 2022-11-01 | | Insurance policy end date | 2023-10-31 | | Total amount of commissions paid to insurance broker | USD $9,834 | | Total amount of fees paid to insurance company | USD $1,675 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $180,937 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HIGHMARK BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 54771 ) |
| Policy contract number | 105980 |
| Policy instance | 3 |
| Insurance contract or identification number | 105980 | | Number of Individuals Covered | 2828 | | Insurance policy start date | 2023-01-01 | | Insurance policy end date | 2023-12-31 | | Total amount of commissions paid to insurance broker | USD $131,573 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $166,921 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MADISON NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65781 ) |
| Policy contract number | 8431-MNL |
| Policy instance | 2 |
| Insurance contract or identification number | 8431-MNL | | Number of Individuals Covered | 1525 | | Insurance policy start date | 2023-01-01 | | Insurance policy end date | 2023-12-31 | | Total amount of commissions paid to insurance broker | USD $15,926 | | Total amount of fees paid to insurance company | USD $30,715 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $455,034 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| DELTA DENTAL OF PENNSYLVANIA (National Association of Insurance Commissioners NAIC id number: 54798 ) |
| Policy contract number | 6789 |
| Policy instance | 1 |
| Insurance contract or identification number | 6789 | | Number of Individuals Covered | 2799 | | Insurance policy start date | 2023-01-01 | | Insurance policy end date | 2023-12-31 | | Total amount of commissions paid to insurance broker | USD $13,546 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $677,306 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| DELTA DENTAL OF PENNSYLVANIA (National Association of Insurance Commissioners NAIC id number: 54798 ) |
| Policy contract number | 6789 |
| Policy instance | 1 |
| Insurance contract or identification number | 6789 | | Number of Individuals Covered | 2702 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $13,082 | | 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 $654,080 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $13,082 | | Insurance broker organization code? | 3 |
|
| MADISON NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65781 ) |
| Policy contract number | 8431-MNL |
| Policy instance | 2 |
| Insurance contract or identification number | 8431-MNL | | Number of Individuals Covered | 1483 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $13,857 | | Total amount of fees paid to insurance company | USD $26,724 | | 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 | 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 $395,904 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 26724 | | Additional information about fees paid to insurance broker | TPA FEES & OVERRIDES | | Insurance broker organization code? | 5 | | Commission paid to Insurance Broker | USD $13,857 |
|
| HIGHMARK BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 54771 ) |
| Policy contract number | 105980 |
| Policy instance | 3 |
| Insurance contract or identification number | 105980 | | Number of Individuals Covered | 2567 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | 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 | 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 $153,741 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| SYMETRA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68608 ) |
| Policy contract number | 01-017605-00 |
| Policy instance | 4 |
| Insurance contract or identification number | 01-017605-00 | | Number of Individuals Covered | 1113 | | Insurance policy start date | 2021-11-01 | | Insurance policy end date | 2022-10-31 | | Total amount of commissions paid to insurance broker | USD $9,013 | | Total amount of fees paid to insurance company | USD $1,793 | | 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 $181,182 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $9,013 | | Amount paid for insurance broker fees | 1793 | | Additional information about fees paid to insurance broker | GROUP VOLUME BONUS | | Insurance broker organization code? | 3 |
|
| SYMETRA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68608 ) |
| Policy contract number | 01-017605-00 |
| Policy instance | 4 |
| Insurance contract or identification number | 01-017605-00 | | Number of Individuals Covered | 1062 | | Insurance policy start date | 2020-11-01 | | Insurance policy end date | 2021-10-31 | | Total amount of commissions paid to insurance broker | USD $8,718 | | Total amount of fees paid to insurance company | USD $1,566 | | 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 $189,191 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,718 | | Amount paid for insurance broker fees | 1566 | | Additional information about fees paid to insurance broker | GROUP VOLUME BONUS | | Insurance broker organization code? | 3 |
|
| HIGHMARK BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 54771 ) |
| Policy contract number | 105980 |
| Policy instance | 3 |
| Insurance contract or identification number | 105980 | | Number of Individuals Covered | 2544 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | 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 | 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 $141,665 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MADISON NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65781 ) |
| Policy contract number | 8431-MNL |
| Policy instance | 2 |
| Insurance contract or identification number | 8431-MNL | | Number of Individuals Covered | 1513 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $20,305 | | Total amount of fees paid to insurance company | USD $33,216 | | 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 | 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 $411,875 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 33216 | | Additional information about fees paid to insurance broker | TPA FEES & OVERRIDES | | Insurance broker organization code? | 5 | | Commission paid to Insurance Broker | USD $20,305 |
|
| DELTA DENTAL OF PENNSYLVANIA (National Association of Insurance Commissioners NAIC id number: 54798 ) |
| Policy contract number | 6789 |
| Policy instance | 1 |
| Insurance contract or identification number | 6789 | | Number of Individuals Covered | 2638 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $12,931 | | 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 $624,675 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $12,931 | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL OF PENNSYLVANIA (National Association of Insurance Commissioners NAIC id number: 54798 ) |
| Policy contract number | 6789 |
| Policy instance | 1 |
| Insurance contract or identification number | 6789 | | Number of Individuals Covered | 2890 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $14,068 | | 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 $703,377 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $14,068 | | Insurance broker organization code? | 3 |
|
| MADISON NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65781 ) |
| Policy contract number | 8431-MNL |
| Policy instance | 2 |
| Insurance contract or identification number | 8431-MNL | | Number of Individuals Covered | 1682 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $28,598 | | Total amount of fees paid to insurance company | USD $45,921 | | 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 | 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 $467,391 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 45921 | | Additional information about fees paid to insurance broker | TPA FEES & OVERRIDES | | Insurance broker organization code? | 5 | | Commission paid to Insurance Broker | USD $28,598 |
|
| HIGHMARK BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 54771 ) |
| Policy contract number | 105980 |
| Policy instance | 3 |
| Insurance contract or identification number | 105980 | | Number of Individuals Covered | 2623 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | 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 | 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 $162,586 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| SYMETRA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68608 ) |
| Policy contract number | 01-017605-00 |
| Policy instance | 4 |
| Insurance contract or identification number | 01-017605-00 | | Number of Individuals Covered | 999 | | Insurance policy start date | 2019-11-01 | | Insurance policy end date | 2020-10-31 | | Total amount of commissions paid to insurance broker | USD $7,978 | | Total amount of fees paid to insurance company | USD $2,048 | | 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 $159,556 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,978 | | Amount paid for insurance broker fees | 2048 | | Additional information about fees paid to insurance broker | GROUP VOLUME BONUS | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL OF PENNSYLVANIA (National Association of Insurance Commissioners NAIC id number: 54798 ) |
| Policy contract number | 6789 |
| Policy instance | 1 |
| Insurance contract or identification number | 6789 | | Number of Individuals Covered | 1262 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $13,762 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $688,104 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $13,762 |
|
| MADISON NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65781 ) |
| Policy contract number | 8431-MNL |
| Policy instance | 2 |
| Insurance contract or identification number | 8431-MNL | | Number of Individuals Covered | 1739 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $15,485 | | Total amount of fees paid to insurance company | USD $39,819 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $442,433 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $15,485 | | Amount paid for insurance broker fees | 39819 |
|
| HIGHMARK BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 54771 ) |
| Policy contract number | 105980 |
| Policy instance | 3 |
| Insurance contract or identification number | 105980 | | Number of Individuals Covered | 994 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $104,894 | | Total amount of fees paid to insurance company | USD $48,081 | | Health Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $104,894 | | Amount paid for insurance broker fees | 48081 |
|
| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
| Policy contract number | 3338187 |
| Policy instance | 4 |
| Insurance contract or identification number | 3338187 | | Number of Individuals Covered | 452 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $28,321 | | Total amount of fees paid to insurance company | USD $194,309 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $28,321 | | Amount paid for insurance broker fees | 194309 | | Insurance broker organization code? | 5 |
|
| SYMETRA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68608 ) |
| Policy contract number | LTD01-017605-00 |
| Policy instance | 5 |
| Insurance contract or identification number | LTD01-017605-00 | | Number of Individuals Covered | 1064 | | Insurance policy start date | 2019-11-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $7,960 | | Total amount of fees paid to insurance company | USD $2,147 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $159,198 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,960 | | Amount paid for insurance broker fees | 2147 | | Insurance broker organization code? | 5 |
|
| SYMETRA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68608 ) |
| Policy contract number | LTD 01-017605-0 |
| Policy instance | 5 |
| Insurance contract or identification number | LTD 01-017605-0 | | Number of Individuals Covered | 1042 | | Insurance policy start date | 2018-11-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $6,781 | | Total amount of fees paid to insurance company | USD $1,619 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $134,876 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,781 | | Amount paid for insurance broker fees | 1619 | | Insurance broker organization code? | 5 |
|
| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
| Policy contract number | 3338187 |
| Policy instance | 4 |
| Insurance contract or identification number | 3338187 | | Number of Individuals Covered | 610 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $25,726 | | Total amount of fees paid to insurance company | USD $165,045 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $25,726 | | Amount paid for insurance broker fees | 165045 | | Insurance broker organization code? | 5 |
|
| HIGHMARK BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 54771 ) |
| Policy contract number | 105980 |
| Policy instance | 3 |
| Insurance contract or identification number | 105980 | | Number of Individuals Covered | 977 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $72,529 | | Total amount of fees paid to insurance company | USD $46,439 | | Health Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $72,529 | | Amount paid for insurance broker fees | 46439 | | Insurance broker organization code? | 5 |
|
| FOUR EVER LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80985 ) |
| Policy contract number | LO 8431 (1 & 2) |
| Policy instance | 2 |
| Insurance contract or identification number | LO 8431 (1 & 2) | | Number of Individuals Covered | 1713 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $14,545 | | Total amount of fees paid to insurance company | USD $37,402 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $415,583 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $14,545 | | Amount paid for insurance broker fees | 37402 |
|
| DELTA DENTAL OF PENNSYLVANIA (National Association of Insurance Commissioners NAIC id number: 54798 ) |
| Policy contract number | 6789 |
| Policy instance | 1 |
| Insurance contract or identification number | 6789 | | Number of Individuals Covered | 1226 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $13,350 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $667,518 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $13,350 |
|
| SYMETRA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68608 ) |
| Policy contract number | LTD 01-017605-0 |
| Policy instance | 6 |
| Insurance contract or identification number | LTD 01-017605-0 | | Number of Individuals Covered | 961 | | Insurance policy start date | 2017-11-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $1,907 | | Total amount of fees paid to insurance company | USD $0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $38,141 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,907 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 5 | | Insurance broker name | MERCER HEALTH & BENEFITS LLC |
|
| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
| Policy contract number | 3338187 |
| Policy instance | 5 |
| Insurance contract or identification number | 3338187 | | Number of Individuals Covered | 613 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $25,922 | | Total amount of fees paid to insurance company | USD $154,276 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $25,922 | | Amount paid for insurance broker fees | 154276 | | Insurance broker organization code? | 5 | | Insurance broker name | MERCER HEALTH & BENEFITS LLC |
|
| HIGHMARK BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 54771 ) |
| Policy contract number | 105980 |
| Policy instance | 4 |
| Insurance contract or identification number | 105980 | | Number of Individuals Covered | 1035 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $156,054 | | Total amount of fees paid to insurance company | USD $40,596 | | Health Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $156,054 | | Amount paid for insurance broker fees | 40596 | | Insurance broker organization code? | 5 | | Insurance broker name | MERCER HEALTH & BENEFITS, LLC |
|
| FOUR EVER LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80985 ) |
| Policy contract number | LO 8431 (1 & 2) |
| Policy instance | 3 |
| Insurance contract or identification number | LO 8431 (1 & 2) | | Number of Individuals Covered | 1591 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $13,539 | | Total amount of fees paid to insurance company | USD $39,106 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $458,352 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $13,539 | | Amount paid for insurance broker fees | 39106 | | Insurance broker name | MERCER HEALTH & BENEFITS LLC |
|
| DELTA DENTAL OF PENNSYLVANIA (National Association of Insurance Commissioners NAIC id number: 54798 ) |
| Policy contract number | 6789 |
| Policy instance | 2 |
| Insurance contract or identification number | 6789 | | Number of Individuals Covered | 1145 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $12,832 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $641,587 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $12,832 | | Amount paid for insurance broker fees | 0 | | Insurance broker name | MERCER HEALTH & BENEFITS LLC |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | LTD 123712 |
| Policy instance | 1 |
| Insurance contract or identification number | LTD 123712 | | Number of Individuals Covered | 1095 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-10-31 | | Total amount of commissions paid to insurance broker | USD $5,319 | | Total amount of fees paid to insurance company | USD $697 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $131,919 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,319 | | Amount paid for insurance broker fees | 697 | | Insurance broker organization code? | 5 | | Insurance broker name | MERCER HEALTH & BENEFITS LLC |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | LTD 123712 |
| Policy instance | 1 |
| Insurance contract or identification number | LTD 123712 | | Number of Individuals Covered | 1233 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $5,757 | | Total amount of fees paid to insurance company | USD $878 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $168,014 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,757 | | Amount paid for insurance broker fees | 878 | | Insurance broker organization code? | 5 | | Insurance broker name | MERCER HEALTH & BENEFITS LLC |
|
| DELTA DENTAL OF PENNSYLVANIA (National Association of Insurance Commissioners NAIC id number: 54798 ) |
| Policy contract number | 6789 |
| Policy instance | 2 |
| Insurance contract or identification number | 6789 | | Number of Individuals Covered | 1362 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $14,907 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $745,344 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $14,907 | | Amount paid for insurance broker fees | 0 | | Insurance broker name | MERCER HEALTH & BENEFITS LLC |
|
| FOUR EVER LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80985 ) |
| Policy contract number | LO 8431 (1 & 2) |
| Policy instance | 3 |
| Insurance contract or identification number | LO 8431 (1 & 2) | | Number of Individuals Covered | 1883 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $16,001 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $493,835 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $16,001 | | Amount paid for insurance broker fees | 0 | | Insurance broker name | MERCER HEALTH & BENEFITS LLC |
|
| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
| Policy contract number | 3338187 |
| Policy instance | 5 |
| Insurance contract or identification number | 3338187 | | Number of Individuals Covered | 161 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $29,224 | | Total amount of fees paid to insurance company | USD $166,933 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $29,224 | | Amount paid for insurance broker fees | 166933 | | Additional information about fees paid to insurance broker | MEDICAL FEES | | Insurance broker organization code? | 5 | | Insurance broker name | MERCER HEALTH & BENEFITS LLC |
|
| HIGHMARK BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 54771 ) |
| Policy contract number | 105980 |
| Policy instance | 4 |
| Insurance contract or identification number | 105980 | | Number of Individuals Covered | 1252 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $132,133 | | Total amount of fees paid to insurance company | USD $64,636 | | Health Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $132,133 | | Amount paid for insurance broker fees | 64636 | | Additional information about fees paid to insurance broker | RETAIL PHARMACY DISPENSING FEE - BLUE CARD | | Insurance broker organization code? | 5 | | Insurance broker name | MERCER HEALTH & BENEFITS, LLC |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | LTD 123712 |
| Policy instance | 1 |
| Insurance contract or identification number | LTD 123712 | | Number of Individuals Covered | 1063 | | Insurance policy start date | 2014-11-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $3,144 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $23,936 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,144 | | Amount paid for insurance broker fees | 3144 | | Insurance broker organization code? | 5 | | Insurance broker name | MERCER HEALTH & BENEFITS LLC |
|
| DELTA DENTAL OF PENNSYLVANIA (National Association of Insurance Commissioners NAIC id number: 54798 ) |
| Policy contract number | 6789 |
| Policy instance | 2 |
| Insurance contract or identification number | 6789 | | Number of Individuals Covered | 1224 | | Insurance policy start date | 2014-11-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $2,262 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $113,101 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,262 | | Insurance broker name | MERCER HEALTH & BENEFITS LLC |
|
| HIGHMARK BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 54771 ) |
| Policy contract number | 105980 |
| Policy instance | 3 |
| Insurance contract or identification number | 105980 | | Number of Individuals Covered | 1215 | | Insurance policy start date | 2014-11-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $22,553 | | Total amount of fees paid to insurance company | USD $34,059 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Health Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $22,553 | | Amount paid for insurance broker fees | 5290 | | Additional information about fees paid to insurance broker | RETAIL PHARMACY DISPENSING FEE | | Insurance broker organization code? | 5 | | Insurance broker name | MERCER HEALTH & BENEFITS, LLC |
|
| HIGHMARK BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 54771 ) |
| Policy contract number | 105980 |
| Policy instance | 4 |
| Insurance contract or identification number | 105980 | | Number of Individuals Covered | 1298 | | Insurance policy start date | 2013-11-01 | | Insurance policy end date | 2014-10-31 | | Total amount of commissions paid to insurance broker | USD $133,214 | | Total amount of fees paid to insurance company | USD $34,059 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Health Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $133,214 | | Amount paid for insurance broker fees | 34059 | | Additional information about fees paid to insurance broker | RETAIL PHARMACY DISPENSING FEERETAIL PHARMACY DISPENSING FEE | | Insurance broker organization code? | 5 | | Insurance broker name | MERCER HEALTH & BENEFITS, LLC |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | LTD 123712 |
| Policy instance | 1 |
| Insurance contract or identification number | LTD 123712 | | Number of Individuals Covered | 1196 | | Insurance policy start date | 2013-11-01 | | Insurance policy end date | 2014-10-31 | | Total amount of commissions paid to insurance broker | USD $5,642 | | Total amount of fees paid to insurance company | USD $5,164 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $164,180 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,642 | | Amount paid for insurance broker fees | 5164 | | Insurance broker organization code? | 5 | | Insurance broker name | MERCER HEALTH & BENEFITS LLC |
|
| DELTA DENTAL OF PENNSYLVANIA (National Association of Insurance Commissioners NAIC id number: 54798 ) |
| Policy contract number | 6789 |
| Policy instance | 2 |
| Insurance contract or identification number | 6789 | | Number of Individuals Covered | 1213 | | Insurance policy start date | 2013-11-01 | | Insurance policy end date | 2014-10-31 | | Total amount of commissions paid to insurance broker | USD $13,755 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $687,761 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $13,755 | | Insurance broker name | MERCER HEALTH & BENEFITS LLC |
|
| FOUR EVER LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80985 ) |
| Policy contract number | LO 8431 (1 & 2) |
| Policy instance | 3 |
| Insurance contract or identification number | LO 8431 (1 & 2) | | Number of Individuals Covered | 1749 | | Insurance policy start date | 2013-11-01 | | Insurance policy end date | 2014-10-31 | | Total amount of commissions paid to insurance broker | USD $14,387 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $411,046 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $14,387 | | Insurance broker name | MERCER HEALTH & BENEFITS LLC |
|
| DELTA DENTAL OF PENNSYLVANIA (National Association of Insurance Commissioners NAIC id number: 54798 ) |
| Policy contract number | 6789 |
| Policy instance | 2 |
| Insurance contract or identification number | 6789 | | Number of Individuals Covered | 1231 | | Insurance policy start date | 2012-11-01 | | Insurance policy end date | 2013-10-31 | | Total amount of commissions paid to insurance broker | USD $13,709 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $691,095 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $13,709 | | Insurance broker name | MERCER HEALTH & BENEFITS LLC |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | LTD 123712 |
| Policy instance | 1 |
| Insurance contract or identification number | LTD 123712 | | Number of Individuals Covered | 972 | | Insurance policy start date | 2012-11-01 | | Insurance policy end date | 2013-10-31 | | Total amount of commissions paid to insurance broker | USD $5,414 | | Total amount of fees paid to insurance company | USD $611 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $151,023 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,414 | | Amount paid for insurance broker fees | 611 | | Additional information about fees paid to insurance broker | TOTAL ADMINISTRATIVE AND OTHER FEES | | Insurance broker organization code? | 5 | | Insurance broker name | MERCER HEALTH & BENEFITS LLC |
|
| FOUR EVER LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80985 ) |
| Policy contract number | LO 8431 (1 & 2) |
| Policy instance | 3 |
| Insurance contract or identification number | LO 8431 (1 & 2) | | Number of Individuals Covered | 1671 | | Insurance policy start date | 2012-11-01 | | Insurance policy end date | 2013-10-31 | | Total amount of commissions paid to insurance broker | USD $12,876 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $367,886 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $12,876 | | Insurance broker name | MERCER HEALTH & BENEFITS LLC |
|
| HIGHMARK BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 54771 ) |
| Policy contract number | 105980 |
| Policy instance | 4 |
| Insurance contract or identification number | 105980 | | Number of Individuals Covered | 1243 | | Insurance policy start date | 2012-11-01 | | Insurance policy end date | 2013-10-31 | | Total amount of commissions paid to insurance broker | USD $123,405 | | Total amount of fees paid to insurance company | USD $30,702 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Health Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $123,405 | | Amount paid for insurance broker fees | 30702 | | Additional information about fees paid to insurance broker | RETAIL PHARMACY DISPENSING FEE | | Insurance broker organization code? | 5 | | Insurance broker name | MERCER HEALTH & BENEFITS, LLC |
|
| DELTA DENTAL OF PENNSYLVANIA (National Association of Insurance Commissioners NAIC id number: 54798 ) |
| Policy contract number | 6789 |
| Policy instance | 2 |
| Insurance contract or identification number | 6789 | | Number of Individuals Covered | 1195 | | Insurance policy start date | 2011-11-01 | | Insurance policy end date | 2012-10-31 | | Total amount of commissions paid to insurance broker | USD $12,651 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $632,561 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HIGHMARK BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 54771 ) |
| Policy contract number | 105980 |
| Policy instance | 4 |
| Insurance contract or identification number | 105980 | | Number of Individuals Covered | 2855 | | Insurance policy start date | 2011-11-01 | | Insurance policy end date | 2012-10-31 | | Total amount of commissions paid to insurance broker | USD $126,204 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Health Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| FOUR EVER LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80985 ) |
| Policy contract number | LO 8431 (1 & 2) |
| Policy instance | 3 |
| Insurance contract or identification number | LO 8431 (1 & 2) | | Number of Individuals Covered | 1616 | | Insurance policy start date | 2011-11-01 | | Insurance policy end date | 2012-10-31 | | Total amount of commissions paid to insurance broker | USD $11,808 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $337,367 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | LTD 202186 |
| Policy instance | 1 |
| Insurance contract or identification number | LTD 202186 | | Number of Individuals Covered | 1027 | | Insurance policy start date | 2011-11-01 | | Insurance policy end date | 2012-10-31 | | Total amount of commissions paid to insurance broker | USD $7,414 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $143,259 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| FOUR EVER LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80985 ) |
| Policy contract number | LO 8431 (1 & 2) |
| Policy instance | 3 |
| Insurance contract or identification number | LO 8431 (1 & 2) | | Number of Individuals Covered | 1522 | | Insurance policy start date | 2010-11-01 | | Insurance policy end date | 2011-10-31 | | Total amount of commissions paid to insurance broker | USD $9,819 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $280,561 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| DELTA DENTAL OF PENNSYLVANIA (National Association of Insurance Commissioners NAIC id number: 54798 ) |
| Policy contract number | 6789 |
| Policy instance | 2 |
| Insurance contract or identification number | 6789 | | Number of Individuals Covered | 1085 | | Insurance policy start date | 2010-11-01 | | Insurance policy end date | 2011-10-31 | | Total amount of commissions paid to insurance broker | USD $11,904 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $595,225 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | LTD 202186 |
| Policy instance | 1 |
| Insurance contract or identification number | LTD 202186 | | Number of Individuals Covered | 799 | | Insurance policy start date | 2010-11-01 | | Insurance policy end date | 2011-10-31 | | Total amount of commissions paid to insurance broker | USD $5,189 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $133,176 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HIGHMARK BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 54771 ) |
| Policy contract number | 105980 |
| Policy instance | 4 |
| Insurance contract or identification number | 105980 | | Number of Individuals Covered | 2603 | | Insurance policy start date | 2010-11-01 | | Insurance policy end date | 2011-10-31 | | Total amount of commissions paid to insurance broker | USD $116,794 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Health Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
