PENNSYLVANIA FARM BUREAU has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan PENNSYLVANIA FARM BUREAU WELFARE WRAP PLAN
| Measure | Date | Value |
|---|
| 2022: PENNSYLVANIA FARM BUREAU WELFARE WRAP PLAN 2022 401k membership |
|---|
| Total participants, beginning-of-year | 2022-01-01 | 67 |
| Total number of active participants reported on line 7a of the Form 5500 | 2022-01-01 | 48 |
| Number of other retired or separated participants entitled to future benefits | 2022-01-01 | 3 |
| Total of all active and inactive participants | 2022-01-01 | 51 |
| 2021: PENNSYLVANIA FARM BUREAU WELFARE WRAP PLAN 2021 401k membership |
|---|
| Total participants, beginning-of-year | 2021-01-01 | 60 |
| Total number of active participants reported on line 7a of the Form 5500 | 2021-01-01 | 64 |
| Number of other retired or separated participants entitled to future benefits | 2021-01-01 | 3 |
| Total of all active and inactive participants | 2021-01-01 | 67 |
| 2020: PENNSYLVANIA FARM BUREAU WELFARE WRAP PLAN 2020 401k membership |
|---|
| Total participants, beginning-of-year | 2020-01-01 | 93 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-01-01 | 57 |
| Number of other retired or separated participants entitled to future benefits | 2020-01-01 | 3 |
| Total of all active and inactive participants | 2020-01-01 | 60 |
| 2019: PENNSYLVANIA FARM BUREAU WELFARE WRAP PLAN 2019 401k membership |
|---|
| Total participants, beginning-of-year | 2019-01-01 | 97 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-01-01 | 90 |
| Number of other retired or separated participants entitled to future benefits | 2019-01-01 | 3 |
| Total of all active and inactive participants | 2019-01-01 | 93 |
| 2018: PENNSYLVANIA FARM BUREAU WELFARE WRAP PLAN 2018 401k membership |
|---|
| Total participants, beginning-of-year | 2018-01-01 | 108 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-01-01 | 93 |
| Number of other retired or separated participants entitled to future benefits | 2018-01-01 | 4 |
| Total of all active and inactive participants | 2018-01-01 | 97 |
| 2017: PENNSYLVANIA FARM BUREAU WELFARE WRAP PLAN 2017 401k membership |
|---|
| Total participants, beginning-of-year | 2017-01-01 | 109 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-01-01 | 104 |
| Number of other retired or separated participants entitled to future benefits | 2017-01-01 | 4 |
| Total of all active and inactive participants | 2017-01-01 | 108 |
| 2016: PENNSYLVANIA FARM BUREAU WELFARE WRAP PLAN 2016 401k membership |
|---|
| Total participants, beginning-of-year | 2016-01-01 | 117 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-01-01 | 105 |
| Number of retired or separated participants receiving benefits | 2016-01-01 | 4 |
| Total of all active and inactive participants | 2016-01-01 | 109 |
| 2015: PENNSYLVANIA FARM BUREAU WELFARE WRAP PLAN 2015 401k membership |
|---|
| Total participants, beginning-of-year | 2015-01-01 | 112 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-01-01 | 109 |
| Number of retired or separated participants receiving benefits | 2015-01-01 | 8 |
| Total of all active and inactive participants | 2015-01-01 | 117 |
| 2014: PENNSYLVANIA FARM BUREAU WELFARE WRAP PLAN 2014 401k membership |
|---|
| Total participants, beginning-of-year | 2014-01-01 | 116 |
| Total number of active participants reported on line 7a of the Form 5500 | 2014-01-01 | 102 |
| Number of retired or separated participants receiving benefits | 2014-01-01 | 10 |
| Total of all active and inactive participants | 2014-01-01 | 112 |
| 2013: PENNSYLVANIA FARM BUREAU WELFARE WRAP PLAN 2013 401k membership |
|---|
| Total participants, beginning-of-year | 2013-01-01 | 113 |
| Total number of active participants reported on line 7a of the Form 5500 | 2013-01-01 | 105 |
| Number of retired or separated participants receiving benefits | 2013-01-01 | 11 |
| Total of all active and inactive participants | 2013-01-01 | 116 |
| 2012: PENNSYLVANIA FARM BUREAU WELFARE WRAP PLAN 2012 401k membership |
|---|
| Total participants, beginning-of-year | 2012-01-01 | 110 |
| Total number of active participants reported on line 7a of the Form 5500 | 2012-01-01 | 102 |
| Number of retired or separated participants receiving benefits | 2012-01-01 | 11 |
| Total of all active and inactive participants | 2012-01-01 | 113 |
| 2011: PENNSYLVANIA FARM BUREAU WELFARE WRAP PLAN 2011 401k membership |
|---|
| Total participants, beginning-of-year | 2011-01-01 | 114 |
| Total number of active participants reported on line 7a of the Form 5500 | 2011-01-01 | 99 |
| Number of retired or separated participants receiving benefits | 2011-01-01 | 11 |
| Total of all active and inactive participants | 2011-01-01 | 110 |
| 2010: PENNSYLVANIA FARM BUREAU WELFARE WRAP PLAN 2010 401k membership |
|---|
| Total participants, beginning-of-year | 2010-01-01 | 104 |
| Total number of active participants reported on line 7a of the Form 5500 | 2010-01-01 | 103 |
| Number of retired or separated participants receiving benefits | 2010-01-01 | 11 |
| Total of all active and inactive participants | 2010-01-01 | 114 |
| 2009: PENNSYLVANIA FARM BUREAU WELFARE WRAP PLAN 2009 401k membership |
|---|
| Total participants, beginning-of-year | 2009-01-01 | 112 |
| Total number of active participants reported on line 7a of the Form 5500 | 2009-01-01 | 93 |
| Number of retired or separated participants receiving benefits | 2009-01-01 | 11 |
| Total of all active and inactive participants | 2009-01-01 | 104 |
| Number of employers contributing to the scheme | 2009-01-01 | 2 |
| AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 ) |
| Policy contract number | 822723296 |
| Policy instance | 5 |
| Insurance contract or identification number | 822723296 | | Number of Individuals Covered | 2 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $225 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | CANCER CARE | | Welfare Benefit Premiums Paid to Carrier | USD $1,892 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $91 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000BRP5 |
| Policy instance | 4 |
| Insurance contract or identification number | G000BRP5 | | Number of Individuals Covered | 108 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2023-01-01 | | Total amount of commissions paid to insurance broker | USD $5,033 | | Total amount of fees paid to insurance company | USD $2,230 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $39,241 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,033 | | Amount paid for insurance broker fees | 2230 | | Insurance broker organization code? | 3 |
|
| HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93440 ) |
| Policy contract number | PFB 001 |
| Policy instance | 3 |
| Insurance contract or identification number | PFB 001 | | Number of Individuals Covered | 1979 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $140,171 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 ) |
| Policy contract number | 259334-000 |
| Policy instance | 2 |
| Insurance contract or identification number | 259334-000 | | Number of Individuals Covered | 2252 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $80,486 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $80,486 |
|
| CAPITAL ADVANTAGE ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 14411 ) |
| Policy contract number | 525477 |
| Policy instance | 1 |
| Insurance contract or identification number | 525477 | | Number of Individuals Covered | 86 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $13,992 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $567,439 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $13,992 |
|
| UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 ) |
| Policy contract number | 259334-000 |
| Policy instance | 2 |
| Insurance contract or identification number | 259334-000 | | Number of Individuals Covered | 2408 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $79,493 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $79,493 |
|
| HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93440 ) |
| Policy contract number | PFB 001 |
| Policy instance | 3 |
| Insurance contract or identification number | PFB 001 | | Number of Individuals Covered | 1897 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $152,278 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 ) |
| Policy contract number | 822723296 |
| Policy instance | 5 |
| Insurance contract or identification number | 822723296 | | Number of Individuals Covered | 1 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $225 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | CANCER CARE | | Welfare Benefit Premiums Paid to Carrier | USD $1,892 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $91 |
|
| CAPITAL ADVANTAGE ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 14411 ) |
| Policy contract number | 525477 |
| Policy instance | 1 |
| Insurance contract or identification number | 525477 | | Number of Individuals Covered | 138 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $16,632 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $630,416 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $16,632 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000BRP5 |
| Policy instance | 4 |
| Insurance contract or identification number | G000BRP5 | | Number of Individuals Covered | 209 | | Insurance policy start date | 2021-09-01 | | Insurance policy end date | 2022-01-01 | | Total amount of commissions paid to insurance broker | USD $5,668 | | Total amount of fees paid to insurance company | USD $1,777 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $44,322 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,668 | | Amount paid for insurance broker fees | 1777 | | Insurance broker organization code? | 3 |
|
| UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 ) |
| Policy contract number | 259334-000 |
| Policy instance | 3 |
| Insurance contract or identification number | 259334-000 | | Number of Individuals Covered | 2636 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $71,590 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $71,590 |
|
| CAPITAL ADVANTAGE ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 14411 ) |
| Policy contract number | 525477 |
| Policy instance | 2 |
| Insurance contract or identification number | 525477 | | Number of Individuals Covered | 102 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $19,416 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $764,546 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $19,416 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | |
| Policy instance | 5 |
| Number of Individuals Covered | 198 | | Insurance policy start date | 2020-09-01 | | Insurance policy end date | 2021-01-01 | | Total amount of commissions paid to insurance broker | USD $1,862 | | Total amount of fees paid to insurance company | USD $462 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $14,612 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,862 | | Amount paid for insurance broker fees | 462 | | Insurance broker organization code? | 3 |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | GL 017745 |
| Policy instance | 1 |
| Insurance contract or identification number | GL 017745 | | Number of Individuals Covered | 299 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-08-31 | | Total amount of commissions paid to insurance broker | USD $6,512 | | Total amount of fees paid to insurance company | USD $2,193 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $60,573 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,512 | | Amount paid for insurance broker fees | 2193 | | Additional information about fees paid to insurance broker | ADMINISTRATIVE | | Insurance broker organization code? | 3 |
|
| HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93440 ) |
| Policy contract number | PFB 001 |
| Policy instance | 4 |
| Insurance contract or identification number | PFB 001 | | Number of Individuals Covered | 2255 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $158,222 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| CAPITAL ADVANTAGE ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 14411 ) |
| Policy contract number | 525477 |
| Policy instance | 2 |
| Insurance contract or identification number | 525477 | | Number of Individuals Covered | 152 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $25,080 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $978,650 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $25,080 |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | GL 017745 |
| Policy instance | 1 |
| Insurance contract or identification number | GL 017745 | | Number of Individuals Covered | 297 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $9,753 | | Total amount of fees paid to insurance company | USD $2,348 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $97,441 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $9,753 | | Amount paid for insurance broker fees | 2348 | | Additional information about fees paid to insurance broker | ADMINISTRATIVE | | Insurance broker organization code? | 3 |
|
| HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93440 ) |
| Policy contract number | PFB 001 |
| Policy instance | 4 |
| Insurance contract or identification number | PFB 001 | | Number of Individuals Covered | 2346 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $164,363 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 ) |
| Policy contract number | 259334-000 |
| Policy instance | 3 |
| Insurance contract or identification number | 259334-000 | | Number of Individuals Covered | 2764 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $85,072 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $85,072 |
|
| CAPITAL ADVANTAGE ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 14411 ) |
| Policy contract number | 525477 |
| Policy instance | 2 |
| Insurance contract or identification number | 525477 | | Number of Individuals Covered | 164 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $27,192 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,009,131 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $27,192 |
|
| HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93440 ) |
| Policy contract number | PFB 001 |
| Policy instance | 4 |
| Insurance contract or identification number | PFB 001 | | Number of Individuals Covered | 2455 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $167,409 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 ) |
| Policy contract number | 259334-000 |
| Policy instance | 3 |
| Insurance contract or identification number | 259334-000 | | Number of Individuals Covered | 2826 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $87,864 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $87,864 |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | GL 017745 |
| Policy instance | 1 |
| Insurance contract or identification number | GL 017745 | | Number of Individuals Covered | 342 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $10,406 | | Total amount of fees paid to insurance company | USD $2,476 | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $104,316 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $10,406 | | Amount paid for insurance broker fees | 2476 | | Additional information about fees paid to insurance broker | ADMINISTRATIVE | | Insurance broker organization code? | 3 |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | GL 017745 |
| Policy instance | 1 |
| Insurance contract or identification number | GL 017745 | | Number of Individuals Covered | 337 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $10,772 | | Total amount of fees paid to insurance company | USD $2,491 | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $110,076 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $10,772 | | Amount paid for insurance broker fees | 2491 | | Additional information about fees paid to insurance broker | ADMINISTRATIVE | | Insurance broker organization code? | 3 | | Insurance broker name | GALLAGHER BENEFIT SERVICES |
|
| UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 ) |
| Policy contract number | 259334-000 |
| Policy instance | 3 |
| Insurance contract or identification number | 259334-000 | | Number of Individuals Covered | 2772 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $82,301 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $82,301 | | Insurance broker name | PFB MEMBER SERVICE CORP |
|
| HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93440 ) |
| Policy contract number | PFB 001 |
| Policy instance | 4 |
| Insurance contract or identification number | PFB 001 | | Number of Individuals Covered | 2392 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $157,556 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Insurance broker name | PFB MEMBER SERVICE CORP |
|
| CAPITAL ADVANTAGE ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 14411 ) |
| Policy contract number | 525477 |
| Policy instance | 2 |
| Insurance contract or identification number | 525477 | | Number of Individuals Covered | 198 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $28,992 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $978,785 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $28,992 | | Insurance broker name | PFB MEMBER SERVICE CORP |
|
| HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93440 ) |
| Policy contract number | PFB 001 |
| Policy instance | 4 |
| Insurance contract or identification number | PFB 001 | | Number of Individuals Covered | 2504 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $147,580 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| UNITED CONCORDIA LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62294 ) |
| Policy contract number | 259334-000 |
| Policy instance | 3 |
| Insurance contract or identification number | 259334-000 | | Number of Individuals Covered | 2940 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $76,747 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $76,747 | | Insurance broker name | PFB MEMBER SERVICE CORP |
|
| CAPITAL ADVANTAGE ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 14411 ) |
| Policy contract number | 525477 |
| Policy instance | 2 |
| Insurance contract or identification number | 525477 | | Number of Individuals Covered | 200 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $28,272 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $846,349 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $28,272 | | Insurance broker name | PFB MEMBER SERVICE CORP |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | GL 017745 |
| Policy instance | 1 |
| Insurance contract or identification number | GL 017745 | | Number of Individuals Covered | 335 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $10,527 | | Total amount of fees paid to insurance company | USD $2,426 | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $108,397 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $10,527 | | Amount paid for insurance broker fees | 2426 | | Additional information about fees paid to insurance broker | ADMINISTRATIVE | | Insurance broker organization code? | 3 | | Insurance broker name | GALLAGHER BENEFIT SERVICES |
|
| UNITED CONCORDIA LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62294 ) |
| Policy contract number | 259334-000 |
| Policy instance | 4 |
| Insurance contract or identification number | 259334-000 | | Number of Individuals Covered | 3020 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $75,822 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $75,822 | | Insurance broker name | PFB MEMBER SERVICE CORP |
|
| CAPITAL ADVANTAGE ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 14411 ) |
| Policy contract number | 503322 |
| Policy instance | 3 |
| Insurance contract or identification number | 503322 | | Number of Individuals Covered | 144 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Health Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| CAPITAL ADVANTAGE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 41203 ) |
| Policy contract number | 503322 |
| Policy instance | 2 |
| Insurance contract or identification number | 503322 | | Number of Individuals Covered | 2768 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Health Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | GL 017745 |
| Policy instance | 1 |
| Insurance contract or identification number | GL 017745 | | Number of Individuals Covered | 344 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $10,486 | | Total amount of fees paid to insurance company | USD $2,330 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $107,778 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $10,486 | | Amount paid for insurance broker fees | 2330 | | Additional information about fees paid to insurance broker | ADMINISTRATIVE FEES | | Insurance broker organization code? | 3 | | Insurance broker name | GALLAGHER BENEFIT SERVICES |
|
| HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93440 ) |
| Policy contract number | PFB 001 - 005 |
| Policy instance | 5 |
| Insurance contract or identification number | PFB 001 - 005 | | Number of Individuals Covered | 2609 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $156,666 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| UNITED CONCORDIA LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62294 ) |
| Policy contract number | 259334-000 |
| Policy instance | 4 |
| Insurance contract or identification number | 259334-000 | | Number of Individuals Covered | 3188 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| DAVIS VISION (National Association of Insurance Commissioners NAIC id number: 93440 ) |
| Policy contract number | PFB 001 - 005 |
| Policy instance | 5 |
| Insurance contract or identification number | PFB 001 - 005 | | Number of Individuals Covered | 1897 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $7,395 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $164,331 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 7395 | | Insurance broker name | HM LIFE INSURANCE COMPANY |
|
| CAPITAL ADVANTAGE ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 14411 ) |
| Policy contract number | 503322 |
| Policy instance | 3 |
| Insurance contract or identification number | 503322 | | Number of Individuals Covered | 5301 | | Insurance policy start date | 2013-04-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Health Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| CAPITAL ADVANTAGE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 41203 ) |
| Policy contract number | 503322 |
| Policy instance | 2 |
| Insurance contract or identification number | 503322 | | Number of Individuals Covered | 3030 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Health Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | GL 017745 |
| Policy instance | 1 |
| Insurance contract or identification number | GL 017745 | | Number of Individuals Covered | 350 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $10,113 | | Total amount of fees paid to insurance company | USD $2,270 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $103,526 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $10,113 | | Amount paid for insurance broker fees | 2270 | | Insurance broker organization code? | 3 | | Insurance broker name | GALLAGHER BENEFIT SERVICES |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | G 017745 |
| Policy instance | 1 |
| Insurance contract or identification number | G 017745 | | Number of Individuals Covered | 341 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $9,930 | | Total amount of fees paid to insurance company | USD $2,164 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $100,908 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $9,930 | | Amount paid for insurance broker fees | 2164 | | Insurance broker organization code? | 3 | | Insurance broker name | GALLAGHER BENEFIT SERVICES |
|
| DAVIS VISION (National Association of Insurance Commissioners NAIC id number: 93440 ) |
| Policy contract number | PFB 001,002 |
| Policy instance | 5 |
| Insurance contract or identification number | PFB 001,002 | | Number of Individuals Covered | 3019 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $7,620 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $169,329 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $0 | | Amount paid for insurance broker fees | 7620 | | Insurance broker name | HM LIFE INSURANCE COMPANY |
|
| UNITED CONCORDIA LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62294 ) |
| Policy contract number | 259334-000 |
| Policy instance | 4 |
| Insurance contract or identification number | 259334-000 | | Number of Individuals Covered | 3375 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| CAPITAL ADVANTAGE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 41203 ) |
| Policy contract number | 53322 |
| Policy instance | 3 |
| Insurance contract or identification number | 53322 | | Number of Individuals Covered | 8891 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Health Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| CAPITAL BLUE CROSS (National Association of Insurance Commissioners NAIC id number: 54720 ) |
| Policy contract number | 00533022 |
| Policy instance | 2 |
| Insurance contract or identification number | 00533022 | | Number of Individuals Covered | 0 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Health Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | G 017745 |
| Policy instance | 1 |
| Insurance contract or identification number | G 017745 | | Number of Individuals Covered | 330 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2011-12-31 | | Total amount of commissions paid to insurance broker | USD $9,389 | | Total amount of fees paid to insurance company | USD $2,107 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $96,140 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| CAPITAL BLUE CROSS (National Association of Insurance Commissioners NAIC id number: 54720 ) |
| Policy contract number | 53322 |
| Policy instance | 2 |
| Insurance contract or identification number | 53322 | | Number of Individuals Covered | 45 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2011-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Health Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| CAPITAL ADVANTAGE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 41203 ) |
| Policy contract number | 53322 |
| Policy instance | 3 |
| Insurance contract or identification number | 53322 | | Number of Individuals Covered | 9863 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2011-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $6,718 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| DAVIS VISION (National Association of Insurance Commissioners NAIC id number: 93440 ) |
| Policy contract number | PFB 001,002 |
| Policy instance | 5 |
| Insurance contract or identification number | PFB 001,002 | | Number of Individuals Covered | 3270 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2011-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $7,646 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Welfare Benefit Premiums Paid to Carrier | USD $169,908 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| UNITED CONCORDIA LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62294 ) |
| Policy contract number | 259334-000 |
| Policy instance | 4 |
| Insurance contract or identification number | 259334-000 | | Number of Individuals Covered | 3296 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2011-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | G 017745 |
| Policy instance | 1 |
| Insurance contract or identification number | G 017745 | | Number of Individuals Covered | 314 | | Insurance policy start date | 2010-01-01 | | Insurance policy end date | 2010-12-31 | | Total amount of commissions paid to insurance broker | USD $7,891 | | Total amount of fees paid to insurance company | USD $1,600 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $85,249 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| CAPITAL BLUE CROSS (National Association of Insurance Commissioners NAIC id number: 54720 ) |
| Policy contract number | 503322 |
| Policy instance | 2 |
| Insurance contract or identification number | 503322 | | Number of Individuals Covered | 72 | | Insurance policy start date | 2010-01-01 | | Insurance policy end date | 2010-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Health Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| UNITED CONCORDIA LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62294 ) |
| Policy contract number | 259334-000 |
| Policy instance | 4 |
| Insurance contract or identification number | 259334-000 | | Number of Individuals Covered | 3426 | | Insurance policy start date | 2010-01-01 | | Insurance policy end date | 2010-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| NATIONAL VISION ADMINISTRATORS, LLC (National Association of Insurance Commissioners NAIC id number: 66842 ) |
| Policy contract number | 00521380 |
| Policy instance | 5 |
| Insurance contract or identification number | 00521380 | | Number of Individuals Covered | 2 | | Insurance policy start date | 2010-01-01 | | Insurance policy end date | 2010-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Welfare Benefit Premiums Paid to Carrier | USD $91 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| DAVIS VISION (National Association of Insurance Commissioners NAIC id number: 93440 ) |
| Policy contract number | PFB 001,002 |
| Policy instance | 6 |
| Insurance contract or identification number | PFB 001,002 | | Number of Individuals Covered | 3475 | | Insurance policy start date | 2010-01-01 | | Insurance policy end date | 2010-12-31 | | Total amount of commissions paid to insurance broker | USD $5,210 | | Total amount of fees paid to insurance company | USD $7,815 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Welfare Benefit Premiums Paid to Carrier | USD $173,688 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| CAPITAL ADVANTAGE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 41203 ) |
| Policy contract number | 503322 |
| Policy instance | 3 |
| Insurance contract or identification number | 503322 | | Number of Individuals Covered | 10716 | | Insurance policy start date | 2010-01-01 | | Insurance policy end date | 2010-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $6,738 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
