HOLT INTERNATIONAL CHILDRENS SERVICES, INC. has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan HOLT INTERNATIONAL CHILDREN'S SERVICES, INC. HEALTH & WELFARE BENEFIT PLAN
401k plan membership statisitcs for HOLT INTERNATIONAL CHILDREN'S SERVICES, INC. HEALTH & WELFARE BENEFIT PLAN
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
Policy contract number | SGM609149 |
Policy instance | 9 |
Insurance contract or identification number | SGM609149 | Number of Individuals Covered | 116 | Insurance policy start date | 2021-10-01 | Insurance policy end date | 2022-09-30 | Total amount of commissions paid to insurance broker | USD $5,398 | Total amount of fees paid to insurance company | USD $0 | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | Yes | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | Welfare Benefit Premiums Paid to Carrier | USD $44,061 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $5,398 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
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PROVIDENCE HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 95005 ) |
Policy contract number | 118479 |
Policy instance | 1 |
Insurance contract or identification number | 118479 | Number of Individuals Covered | 151 | Insurance policy start date | 2021-10-01 | Insurance policy end date | 2022-09-30 | Total amount of commissions paid to insurance broker | USD $21,244 | Total amount of fees paid to insurance company | USD $0 | Health Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $1,008,318 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $21,244 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
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WILLAMETTE DENTAL INSURANCE, INC. (National Association of Insurance Commissioners NAIC id number: 57069 ) |
Policy contract number | OR202 |
Policy instance | 2 |
Insurance contract or identification number | OR202 | Number of Individuals Covered | 53 | Insurance policy start date | 2021-10-01 | Insurance policy end date | 2022-09-30 | Total amount of commissions paid to insurance broker | USD $1,147 | 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? | Yes | Commission paid to Insurance Broker | USD $1,147 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
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CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
Policy contract number | 3342108 |
Policy instance | 3 |
Insurance contract or identification number | 3342108 | Number of Individuals Covered | 73 | Insurance policy start date | 2021-10-01 | Insurance policy end date | 2022-09-30 | Total amount of commissions paid to insurance broker | USD $3,529 | Total amount of fees paid to insurance company | USD $365 | Dental Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $71,210 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $3,529 | Amount paid for insurance broker fees | 365 | Additional information about fees paid to insurance broker | GENERAL AGENT PAYMENTS | Insurance broker organization code? | 3 |
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VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
Policy contract number | 30051412 |
Policy instance | 4 |
Insurance contract or identification number | 30051412 | Number of Individuals Covered | 76 | Insurance policy start date | 2021-10-01 | Insurance policy end date | 2022-09-30 | Total amount of commissions paid to insurance broker | USD $919 | Total amount of fees paid to insurance company | USD $0 | Vision Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $14,712 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $919 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
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CASCADE HEALTH SOLUTIONS (National Association of Insurance Commissioners NAIC id number: 00000 ) |
Policy contract number | 00 |
Policy instance | 5 |
Insurance contract or identification number | 00 | Number of Individuals Covered | 116 | Insurance policy start date | 2021-10-01 | Insurance policy end date | 2022-09-30 | Total amount of commissions paid to insurance broker | USD $0 | Total amount of fees paid to insurance company | USD $0 | Other welfare benefits provided | EMPLOYEE ASSISTANCE PROGRAM | Welfare Benefit Premiums Paid to Carrier | USD $4,037 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 ) |
Policy contract number | E3450442 |
Policy instance | 6 |
Insurance contract or identification number | E3450442 | Number of Individuals Covered | 6 | Insurance policy start date | 2021-10-01 | Insurance policy end date | 2022-09-30 | Total amount of commissions paid to insurance broker | USD $1,017 | Total amount of fees paid to insurance company | USD $188 | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | Yes | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT, CRITICAL ILLNESS, HOSPITAL | Welfare Benefit Premiums Paid to Carrier | USD $5,383 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $341 | Amount paid for insurance broker fees | 43 | Additional information about fees paid to insurance broker | FEES | Insurance broker organization code? | 3 |
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AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 ) |
Policy contract number | 90142 |
Policy instance | 7 |
Insurance contract or identification number | 90142 | Number of Individuals Covered | 5 | Insurance policy start date | 2021-10-01 | Insurance policy end date | 2022-09-30 | Total amount of commissions paid to insurance broker | USD $828 | Total amount of fees paid to insurance company | USD $90 | Temporary Disability Insurance Welfare Benefit | Yes | Other welfare benefits provided | ACCIDENT, CRITICAL ILLNESS, HOSPITAL, CANCER | Welfare Benefit Premiums Paid to Carrier | USD $7,277 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $383 | Amount paid for insurance broker fees | 61 | Additional information about fees paid to insurance broker | FEES | Insurance broker organization code? | 3 |
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UNITED HEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 00000 ) |
Policy contract number | B2BHICS |
Policy instance | 8 |
Insurance contract or identification number | B2BHICS | Number of Individuals Covered | 6 | Insurance policy start date | 2021-10-01 | Insurance policy end date | 2022-09-30 | Total amount of commissions paid to insurance broker | USD $0 | Total amount of fees paid to insurance company | USD $0 | Health Insurance Welfare Benefit | Yes | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
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PROVIDENCE HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 95005 ) |
Policy contract number | 118479 |
Policy instance | 1 |
Insurance contract or identification number | 118479 | Number of Individuals Covered | 169 | Insurance policy start date | 2020-10-01 | Insurance policy end date | 2021-09-30 | Total amount of commissions paid to insurance broker | USD $22,801 | Total amount of fees paid to insurance company | USD $0 | Health Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $1,135,281 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $22,801 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
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WILLAMETTE DENTAL INSURANCE, INC. (National Association of Insurance Commissioners NAIC id number: 57069 ) |
Policy contract number | OR202 |
Policy instance | 2 |
Insurance contract or identification number | OR202 | Number of Individuals Covered | 64 | Insurance policy start date | 2020-10-01 | Insurance policy end date | 2021-09-30 | Total amount of commissions paid to insurance broker | USD $1,384 | 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? | Yes | Commission paid to Insurance Broker | USD $1,384 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
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CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
Policy contract number | 3342108 |
Policy instance | 3 |
Insurance contract or identification number | 3342108 | Number of Individuals Covered | 77 | Insurance policy start date | 2020-10-01 | Insurance policy end date | 2021-09-30 | Total amount of commissions paid to insurance broker | USD $3,721 | Total amount of fees paid to insurance company | USD $324 | Dental Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $75,088 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $3,721 | Amount paid for insurance broker fees | 324 | Additional information about fees paid to insurance broker | GENERAL AGENT PAYMENTS | Insurance broker organization code? | 3 |
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VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
Policy contract number | 30051412 |
Policy instance | 4 |
Insurance contract or identification number | 30051412 | Number of Individuals Covered | 82 | Insurance policy start date | 2020-10-01 | Insurance policy end date | 2021-09-30 | Total amount of commissions paid to insurance broker | USD $953 | Total amount of fees paid to insurance company | USD $0 | Vision Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $15,737 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $953 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
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CASCADE HEALTH SOLUTIONS (National Association of Insurance Commissioners NAIC id number: 00000 ) |
Policy contract number | 00 |
Policy instance | 5 |
Insurance contract or identification number | 00 | Number of Individuals Covered | 133 | Insurance policy start date | 2020-10-01 | Insurance policy end date | 2021-09-30 | Total amount of commissions paid to insurance broker | USD $0 | Total amount of fees paid to insurance company | USD $0 | Other welfare benefits provided | EMPLOYEE ASSISTANCE PROGRAM | Welfare Benefit Premiums Paid to Carrier | USD $5,065 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 ) |
Policy contract number | E3450442 |
Policy instance | 6 |
Insurance contract or identification number | E3450442 | Number of Individuals Covered | 5 | Insurance policy start date | 2020-10-01 | Insurance policy end date | 2021-09-30 | Total amount of commissions paid to insurance broker | USD $786 | Total amount of fees paid to insurance company | USD $152 | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | Yes | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT, CRITICAL ILLNESS, HOSPITAL | Welfare Benefit Premiums Paid to Carrier | USD $5,081 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $255 | Amount paid for insurance broker fees | 37 | Additional information about fees paid to insurance broker | FEES | Insurance broker organization code? | 3 |
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AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 ) |
Policy contract number | 90142 |
Policy instance | 7 |
Insurance contract or identification number | 90142 | Number of Individuals Covered | 6 | Insurance policy start date | 2020-10-01 | Insurance policy end date | 2021-09-30 | Total amount of commissions paid to insurance broker | USD $1,546 | Total amount of fees paid to insurance company | USD $0 | Temporary Disability Insurance Welfare Benefit | Yes | Other welfare benefits provided | ACCIDENT, CRITICAL ILLNESS, HOSPITAL, CANCER | Welfare Benefit Premiums Paid to Carrier | USD $8,262 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $874 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
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UNITED HEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 00000 ) |
Policy contract number | B2BHICS |
Policy instance | 8 |
Insurance contract or identification number | B2BHICS | Number of Individuals Covered | 5 | Insurance policy start date | 2020-10-01 | Insurance policy end date | 2021-09-30 | Total amount of commissions paid to insurance broker | USD $0 | Total amount of fees paid to insurance company | USD $0 | Health Insurance Welfare Benefit | Yes | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
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LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
Policy contract number | SGM609149 |
Policy instance | 9 |
Insurance contract or identification number | SGM609149 | Number of Individuals Covered | 75 | Insurance policy start date | 2020-10-01 | Insurance policy end date | 2021-09-30 | Total amount of commissions paid to insurance broker | USD $5,551 | Total amount of fees paid to insurance company | USD $0 | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | Yes | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | Welfare Benefit Premiums Paid to Carrier | USD $49,295 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $5,551 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
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PROVIDENCE HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 95005 ) |
Policy contract number | 118479 |
Policy instance | 1 |
Insurance contract or identification number | 118479 | Number of Individuals Covered | 176 | Insurance policy start date | 2019-10-01 | Insurance policy end date | 2020-09-30 | Total amount of commissions paid to insurance broker | USD $23,100 | Total amount of fees paid to insurance company | USD $0 | Health Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $1,151,093 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $23,100 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
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LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
Policy contract number | SOK606774 |
Policy instance | 8 |
Insurance contract or identification number | SOK606774 | Number of Individuals Covered | 77 | Insurance policy start date | 2019-10-01 | Insurance policy end date | 2020-09-30 | Total amount of commissions paid to insurance broker | USD $5,779 | Total amount of fees paid to insurance company | USD $0 | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | Yes | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | Welfare Benefit Premiums Paid to Carrier | USD $51,166 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $5,779 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
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AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 ) |
Policy contract number | 90142 |
Policy instance | 7 |
Insurance contract or identification number | 90142 | Number of Individuals Covered | 6 | Insurance policy start date | 2019-10-01 | Insurance policy end date | 2020-09-30 | Total amount of commissions paid to insurance broker | USD $628 | Total amount of fees paid to insurance company | USD $25 | Temporary Disability Insurance Welfare Benefit | Yes | Other welfare benefits provided | ACCIDENT, CRITICAL ILLNESS, HOSPITAL, CANCER | Welfare Benefit Premiums Paid to Carrier | USD $6,538 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $204 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 | Additional information about fees paid to insurance broker | FEES |
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COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 ) |
Policy contract number | E3450442 |
Policy instance | 6 |
Insurance contract or identification number | E3450442 | Number of Individuals Covered | 7 | Insurance policy start date | 2019-10-01 | Insurance policy end date | 2020-09-30 | Total amount of commissions paid to insurance broker | USD $798 | Total amount of fees paid to insurance company | USD $101 | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | Yes | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT, CRITICAL ILLNESS, HOSPITAL | Welfare Benefit Premiums Paid to Carrier | USD $6,042 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $252 | Amount paid for insurance broker fees | 38 | Additional information about fees paid to insurance broker | FEES | Insurance broker organization code? | 3 |
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CASCADE HEALTH SOLUTIONS (National Association of Insurance Commissioners NAIC id number: 00000 ) |
Policy contract number | 00 |
Policy instance | 5 |
Insurance contract or identification number | 00 | Number of Individuals Covered | 164 | Insurance policy start date | 2019-10-01 | Insurance policy end date | 2020-09-30 | Total amount of commissions paid to insurance broker | USD $0 | Total amount of fees paid to insurance company | USD $0 | Other welfare benefits provided | EMPLOYEE ASSISTANCE PROGRAM | Welfare Benefit Premiums Paid to Carrier | USD $4,971 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
Policy contract number | 30051412 |
Policy instance | 4 |
Insurance contract or identification number | 30051412 | Number of Individuals Covered | 82 | Insurance policy start date | 2019-10-01 | Insurance policy end date | 2020-09-30 | Total amount of commissions paid to insurance broker | USD $973 | Total amount of fees paid to insurance company | USD $0 | Vision Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $16,278 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $973 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
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CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
Policy contract number | 3342108 |
Policy instance | 3 |
Insurance contract or identification number | 3342108 | Number of Individuals Covered | 88 | Insurance policy start date | 2019-10-01 | Insurance policy end date | 2020-09-30 | Total amount of commissions paid to insurance broker | USD $3,477 | Total amount of fees paid to insurance company | USD $0 | Dental Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $70,217 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $3,477 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
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WILLAMETTE DENTAL INSURANCE, INC. (National Association of Insurance Commissioners NAIC id number: 57069 ) |
Policy contract number | OR202 |
Policy instance | 2 |
Insurance contract or identification number | OR202 | Number of Individuals Covered | 63 | Insurance policy start date | 2019-10-01 | Insurance policy end date | 2020-09-30 | Total amount of commissions paid to insurance broker | USD $1,459 | 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? | Yes | Commission paid to Insurance Broker | USD $1,459 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
|
AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 ) |
Policy contract number | 90142 |
Policy instance | 7 |
Insurance contract or identification number | 90142 | Number of Individuals Covered | 6 | Insurance policy start date | 2018-10-01 | Insurance policy end date | 2019-09-30 | Total amount of commissions paid to insurance broker | USD $1,820 | Total amount of fees paid to insurance company | USD $240 | Temporary Disability Insurance Welfare Benefit | Yes | Other welfare benefits provided | ACCIDENT, CRITICAL ILLNESS, HOSPITAL, CANCER | Welfare Benefit Premiums Paid to Carrier | USD $5,934 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $727 | Amount paid for insurance broker fees | 88 | Additional information about fees paid to insurance broker | FEES | Insurance broker organization code? | 3 |
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COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 ) |
Policy contract number | E3450442 |
Policy instance | 6 |
Insurance contract or identification number | E3450442 | Number of Individuals Covered | 9 | Insurance policy start date | 2018-10-01 | Insurance policy end date | 2019-09-30 | Total amount of commissions paid to insurance broker | USD $1,987 | Total amount of fees paid to insurance company | USD $879 | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | Yes | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT, CRITICAL ILLNESS, HOSPITAL | Welfare Benefit Premiums Paid to Carrier | USD $5,521 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $569 | Amount paid for insurance broker fees | 438 | Additional information about fees paid to insurance broker | FEES | Insurance broker organization code? | 3 |
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CASCADE HEALTH SOLUTIONS (National Association of Insurance Commissioners NAIC id number: 00000 ) |
Policy contract number | 00 |
Policy instance | 5 |
Insurance contract or identification number | 00 | Number of Individuals Covered | 141 | Insurance policy start date | 2018-10-01 | Insurance policy end date | 2019-09-30 | Total amount of commissions paid to insurance broker | USD $0 | Total amount of fees paid to insurance company | USD $0 | Other welfare benefits provided | EMPLOYEE ASSISTANCE PROGRAM | Welfare Benefit Premiums Paid to Carrier | USD $4,415 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
Policy contract number | 30051412 |
Policy instance | 4 |
Insurance contract or identification number | 30051412 | Number of Individuals Covered | 81 | Insurance policy start date | 2018-10-01 | Insurance policy end date | 2019-09-30 | Total amount of commissions paid to insurance broker | USD $882 | Total amount of fees paid to insurance company | USD $0 | Vision Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $13,805 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $882 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
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CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
Policy contract number | 3342108 |
Policy instance | 3 |
Insurance contract or identification number | 3342108 | Number of Individuals Covered | 86 | Insurance policy start date | 2018-10-01 | Insurance policy end date | 2019-09-30 | Total amount of commissions paid to insurance broker | USD $3,335 | Total amount of fees paid to insurance company | USD $0 | Dental Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $67,336 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $3,335 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
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WILLAMETTE DENTAL INSURANCE, INC. (National Association of Insurance Commissioners NAIC id number: 57069 ) |
Policy contract number | OR202 |
Policy instance | 2 |
Insurance contract or identification number | OR202 | Number of Individuals Covered | 79 | Insurance policy start date | 2018-10-01 | Insurance policy end date | 2019-09-30 | Total amount of commissions paid to insurance broker | USD $1,601 | 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? | Yes | Commission paid to Insurance Broker | USD $1,601 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
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LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
Policy contract number | SOK606774 |
Policy instance | 8 |
Insurance contract or identification number | SOK606774 | Number of Individuals Covered | 141 | Insurance policy start date | 2018-10-01 | Insurance policy end date | 2019-09-30 | Total amount of commissions paid to insurance broker | USD $4,583 | Total amount of fees paid to insurance company | USD $0 | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | No | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | Yes | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | Welfare Benefit Premiums Paid to Carrier | USD $37,573 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | Commission paid to Insurance Broker | USD $4,583 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
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PROVIDENCE HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 95005 ) |
Policy contract number | 118479 |
Policy instance | 1 |
Insurance contract or identification number | 118479 | Number of Individuals Covered | 205 | Insurance policy start date | 2018-10-01 | Insurance policy end date | 2019-09-30 | Total amount of commissions paid to insurance broker | USD $18,033 | Total amount of fees paid to insurance company | USD $0 | Health Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $1,000,029 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $18,033 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 |
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UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
Policy contract number | 909229 |
Policy instance | 1 |
Insurance contract or identification number | 909229 | Number of Individuals Covered | 100 | Insurance policy start date | 2017-10-01 | Insurance policy end date | 2018-09-30 | Total amount of commissions paid to insurance broker | USD $0 | Total amount of fees paid to insurance company | USD $13,697 | Health Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $895,354 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
Policy contract number | 30051412 |
Policy instance | 3 |
Insurance contract or identification number | 30051412 | Number of Individuals Covered | 68 | Insurance policy start date | 2017-10-01 | Insurance policy end date | 2018-09-30 | Total amount of commissions paid to insurance broker | USD $833 | Total amount of fees paid to insurance company | USD $0 | Vision Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $12,342 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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CASCADE HEALTH SOLUTIONS (National Association of Insurance Commissioners NAIC id number: 00000 ) |
Policy contract number | 00 |
Policy instance | 4 |
Insurance contract or identification number | 00 | Number of Individuals Covered | 120 | Insurance policy start date | 2017-10-01 | Insurance policy end date | 2018-09-30 | Total amount of commissions paid to insurance broker | USD $0 | Total amount of fees paid to insurance company | USD $0 | Other welfare benefits provided | EMPLOYEE ASSISTANCE PROGRAM | Welfare Benefit Premiums Paid to Carrier | USD $3,795 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 ) |
Policy contract number | E3450442 |
Policy instance | 5 |
Insurance contract or identification number | E3450442 | Number of Individuals Covered | 6 | Insurance policy start date | 2017-10-01 | Insurance policy end date | 2018-09-30 | Total amount of commissions paid to insurance broker | USD $425 | Total amount of fees paid to insurance company | USD $122 | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | Yes | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT, CRITICAL ILLNESS, HOSPITAL | Welfare Benefit Premiums Paid to Carrier | USD $1,772 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 ) |
Policy contract number | 90142 |
Policy instance | 6 |
Insurance contract or identification number | 90142 | Number of Individuals Covered | 5 | Insurance policy start date | 2017-10-01 | Insurance policy end date | 2018-09-30 | Total amount of commissions paid to insurance broker | USD $750 | Total amount of fees paid to insurance company | USD $0 | Temporary Disability Insurance Welfare Benefit | Yes | Other welfare benefits provided | ACCIDENT, CRITICAL ILLNESS, HOSPITAL, CANCER | Welfare Benefit Premiums Paid to Carrier | USD $3,067 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
Policy contract number | 10208906 |
Policy instance | 7 |
Insurance contract or identification number | 10208906 | Number of Individuals Covered | 112 | Insurance policy start date | 2017-10-01 | Insurance policy end date | 2018-09-30 | Total amount of commissions paid to insurance broker | USD $7,333 | Total amount of fees paid to insurance company | USD $0 | Health Insurance Welfare Benefit | No | Dental Insurance Welfare Benefit | Yes | Vision Insurance Welfare Benefit | No | Life Insurance Welfare Benefit | Yes | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | Yes | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | Welfare Benefit Premiums Paid to Carrier | USD $97,824 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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WILLAMETTE DENTAL INSURANCE, INC. (National Association of Insurance Commissioners NAIC id number: 57069 ) |
Policy contract number | OR202 |
Policy instance | 2 |
Insurance contract or identification number | OR202 | Number of Individuals Covered | 62 | Insurance policy start date | 2017-10-01 | Insurance policy end date | 2018-09-30 | Total amount of commissions paid to insurance broker | USD $1,306 | 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? | Yes |
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