OPTA USA, INC has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan ESM GROUP INC. SELF FUNDED MEDICAL PLAN
401k plan membership statisitcs for ESM GROUP INC. SELF FUNDED MEDICAL PLAN
| Measure | Date | Value |
|---|
| 2020: ESM GROUP INC. SELF FUNDED MEDICAL PLAN 2020 401k membership |
|---|
| Total participants, beginning-of-year | 2020-09-01 | 206 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-09-01 | 206 |
| Number of retired or separated participants receiving benefits | 2020-09-01 | 2 |
| Number of other retired or separated participants entitled to future benefits | 2020-09-01 | 2 |
| Total of all active and inactive participants | 2020-09-01 | 210 |
| 2018: ESM GROUP INC. SELF FUNDED MEDICAL PLAN 2018 401k membership |
|---|
| Total participants, beginning-of-year | 2018-01-01 | 288 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-01-01 | 202 |
| Number of retired or separated participants receiving benefits | 2018-01-01 | 1 |
| Number of other retired or separated participants entitled to future benefits | 2018-01-01 | 0 |
| Total of all active and inactive participants | 2018-01-01 | 203 |
| 2017: ESM GROUP INC. SELF FUNDED MEDICAL PLAN 2017 401k membership |
|---|
| Total participants, beginning-of-year | 2017-01-01 | 344 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-01-01 | 288 |
| Number of retired or separated participants receiving benefits | 2017-01-01 | 2 |
| Number of other retired or separated participants entitled to future benefits | 2017-01-01 | 1 |
| Total of all active and inactive participants | 2017-01-01 | 291 |
| 2016: ESM GROUP INC. SELF FUNDED MEDICAL PLAN 2016 401k membership |
|---|
| Total participants, beginning-of-year | 2016-01-01 | 394 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-01-01 | 344 |
| Number of retired or separated participants receiving benefits | 2016-01-01 | 1 |
| Number of other retired or separated participants entitled to future benefits | 2016-01-01 | 3 |
| Total of all active and inactive participants | 2016-01-01 | 348 |
| 2015: ESM GROUP INC. SELF FUNDED MEDICAL PLAN 2015 401k membership |
|---|
| Total participants, beginning-of-year | 2015-01-01 | 182 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-01-01 | 160 |
| Number of retired or separated participants receiving benefits | 2015-01-01 | 2 |
| Number of other retired or separated participants entitled to future benefits | 2015-01-01 | 0 |
| Total of all active and inactive participants | 2015-01-01 | 162 |
| 2014: ESM GROUP INC. SELF FUNDED MEDICAL PLAN 2014 401k membership |
|---|
| Total participants, beginning-of-year | 2014-01-01 | 207 |
| Total number of active participants reported on line 7a of the Form 5500 | 2014-01-01 | 182 |
| Number of retired or separated participants receiving benefits | 2014-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2014-01-01 | 0 |
| Total of all active and inactive participants | 2014-01-01 | 182 |
| 2013: ESM GROUP INC. SELF FUNDED MEDICAL PLAN 2013 401k membership |
|---|
| Total participants, beginning-of-year | 2013-01-01 | 215 |
| Total number of active participants reported on line 7a of the Form 5500 | 2013-01-01 | 206 |
| Number of retired or separated participants receiving benefits | 2013-01-01 | 1 |
| Total of all active and inactive participants | 2013-01-01 | 207 |
| 2012: ESM GROUP INC. SELF FUNDED MEDICAL PLAN 2012 401k membership |
|---|
| Total participants, beginning-of-year | 2012-01-01 | 217 |
| Total number of active participants reported on line 7a of the Form 5500 | 2012-01-01 | 215 |
| Number of retired or separated participants receiving benefits | 2012-01-01 | 1 |
| Total of all active and inactive participants | 2012-01-01 | 216 |
| 2011: ESM GROUP INC. SELF FUNDED MEDICAL PLAN 2011 401k membership |
|---|
| Total participants, beginning-of-year | 2011-01-01 | 228 |
| Total number of active participants reported on line 7a of the Form 5500 | 2011-01-01 | 226 |
| Number of retired or separated participants receiving benefits | 2011-01-01 | 2 |
| Total of all active and inactive participants | 2011-01-01 | 228 |
| 2010: ESM GROUP INC. SELF FUNDED MEDICAL PLAN 2010 401k membership |
|---|
| Total participants, beginning-of-year | 2010-01-01 | 221 |
| Total number of active participants reported on line 7a of the Form 5500 | 2010-01-01 | 228 |
| Number of retired or separated participants receiving benefits | 2010-01-01 | 2 |
| Total of all active and inactive participants | 2010-01-01 | 230 |
| 2009: ESM GROUP INC. SELF FUNDED MEDICAL PLAN 2009 401k membership |
|---|
| Total participants, beginning-of-year | 2009-01-01 | 203 |
| Total number of active participants reported on line 7a of the Form 5500 | 2009-01-01 | 221 |
| Number of retired or separated participants receiving benefits | 2009-01-01 | 2 |
| Total of all active and inactive participants | 2009-01-01 | 223 |
| 2020: ESM GROUP INC. SELF FUNDED MEDICAL PLAN 2020 form 5500 responses |
|---|
| 2020-09-01 | Type of plan entity | Single employer plan |
| 2020-09-01 | First time form 5500 has been submitted | Yes |
| 2020-09-01 | Plan funding arrangement – Insurance | Yes |
| 2020-09-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2020-09-01 | Plan benefit arrangement – Insurance | Yes |
| 2020-09-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2018: ESM GROUP INC. SELF FUNDED MEDICAL PLAN 2018 form 5500 responses |
|---|
| 2018-01-01 | Type of plan entity | Single employer plan |
| 2018-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2018-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2017: ESM GROUP INC. SELF FUNDED MEDICAL PLAN 2017 form 5500 responses |
|---|
| 2017-01-01 | Type of plan entity | Single employer plan |
| 2017-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2017-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2016: ESM GROUP INC. SELF FUNDED MEDICAL PLAN 2016 form 5500 responses |
|---|
| 2016-01-01 | Type of plan entity | Single employer plan |
| 2016-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2016-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2015: ESM GROUP INC. SELF FUNDED MEDICAL PLAN 2015 form 5500 responses |
|---|
| 2015-01-01 | Type of plan entity | Single employer plan |
| 2015-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2015-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2014: ESM GROUP INC. SELF FUNDED MEDICAL PLAN 2014 form 5500 responses |
|---|
| 2014-01-01 | Type of plan entity | Single employer plan |
| 2014-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2014-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2013: ESM GROUP INC. SELF FUNDED MEDICAL PLAN 2013 form 5500 responses |
|---|
| 2013-01-01 | Type of plan entity | Single employer plan |
| 2013-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2013-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2012: ESM GROUP INC. SELF FUNDED MEDICAL PLAN 2012 form 5500 responses |
|---|
| 2012-01-01 | Type of plan entity | Single employer plan |
| 2012-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2012-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2011: ESM GROUP INC. SELF FUNDED MEDICAL PLAN 2011 form 5500 responses |
|---|
| 2011-01-01 | Type of plan entity | Single employer plan |
| 2011-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2011-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2010: ESM GROUP INC. SELF FUNDED MEDICAL PLAN 2010 form 5500 responses |
|---|
| 2010-01-01 | Type of plan entity | Single employer plan |
| 2010-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2010-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2009: ESM GROUP INC. SELF FUNDED MEDICAL PLAN 2009 form 5500 responses |
|---|
| 2009-01-01 | Type of plan entity | Single employer plan |
| 2009-01-01 | This submission is the final filing | No |
| 2009-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2009-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 00576886 |
| Policy instance | 2 |
| Insurance contract or identification number | 00576886 | | Number of Individuals Covered | 206 | | Insurance policy start date | 2020-09-01 | | Insurance policy end date | 2021-08-31 | | Total amount of commissions paid to insurance broker | USD $26,926 | | Total amount of fees paid to insurance company | USD $9,957 | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D AND CRITICAL ILLNESS | | Welfare Benefit Premiums Paid to Carrier | USD $368,036 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $26,926 | | Amount paid for insurance broker fees | 9957 | | Insurance broker organization code? | 3 |
|
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80012 ) |
| Policy contract number | 0149899 |
| Policy instance | 1 |
| Insurance contract or identification number | 0149899 | | Number of Individuals Covered | 408 | | Insurance policy start date | 2020-09-01 | | Insurance policy end date | 2021-08-31 | | Total amount of commissions paid to insurance broker | USD $82,531 | | Total amount of fees paid to insurance company | USD $40,056 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $2,191,072 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $65,559 | | Amount paid for insurance broker fees | 29449 | | Additional information about fees paid to insurance broker | KEY PRODUCER OVERRIDE 2% | | Insurance broker organization code? | 3 |
|
| HEALTHNOW NEW YORK, INC. DBA BLUESHIELD OF NORTHEASTERN NEW YORK (National Association of Insurance Commissioners NAIC id number: 55204 ) |
| Policy contract number | 00413285 |
| Policy instance | 2 |
| Insurance contract or identification number | 00413285 | | Number of Individuals Covered | 202 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $36,333 | | 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? | No | | Commission paid to Insurance Broker | USD $36,333 | | Insurance broker organization code? | 3 |
|
| EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 ) |
| Policy contract number | 00093962 |
| Policy instance | 1 |
| Insurance contract or identification number | 00093962 | | Number of Individuals Covered | 13 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $12,421 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $279,237 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $12,421 | | Insurance broker organization code? | 3 |
|
| HEALTHNOW NEW YORK, INC. DBA BLUESHIELD OF NORTHEASTERN NEW YORK (National Association of Insurance Commissioners NAIC id number: 55204 ) |
| Policy contract number | 00413285 |
| Policy instance | 2 |
| Insurance contract or identification number | 00413285 | | Number of Individuals Covered | 270 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $43,494 | | 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? | No | | Commission paid to Insurance Broker | USD $43,494 | | Insurance broker organization code? | 3 | | Insurance broker name | BRITTON GALLAGHER & ASSOCIATES |
|
| EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 ) |
| Policy contract number | 00093962 |
| Policy instance | 1 |
| Insurance contract or identification number | 00093962 | | Number of Individuals Covered | 18 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $14,279 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $314,552 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $14,279 | | Insurance broker organization code? | 3 | | Insurance broker name | LIFETIME BENEFIT SOLUTIONS, INC. |
|
| HEALTHNOW NEW YORK, INC. DBA BLUESHIELD OF NORTHEASTERN NEW YORK (National Association of Insurance Commissioners NAIC id number: 55204 ) |
| Policy contract number | 00413285 |
| Policy instance | 3 |
| Insurance contract or identification number | 00413285 | | Number of Individuals Covered | 394 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $89,765 | | 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? | No | | Commission paid to Insurance Broker | USD $60,096 | | Insurance broker name | BRITTON GALLAGHER & ASSOCIATES |
|
| COFINITY (National Association of Insurance Commissioners NAIC id number: ) |
| Policy contract number | H92 |
| Policy instance | 2 |
| Insurance contract or identification number | H92 | | Number of Individuals Covered | 181 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $7,191 | | Total amount of fees paid to insurance company | USD $19,969 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $3,556 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,191 | | Amount paid for insurance broker fees | 19969 | | Additional information about fees paid to insurance broker | ADMINISTRATION FEES | | Insurance broker organization code? | 3 | | Insurance broker name | BROKERAGE CNCPTS INC |
|
| EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 ) |
| Policy contract number | 00093962 |
| Policy instance | 1 |
| Insurance contract or identification number | 00093962 | | Number of Individuals Covered | 23 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $11,825 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $265,078 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,841 | | Insurance broker organization code? | 3 | | Insurance broker name | LIFETIME BENEFIT SOLUTIONS, INC. |
|
| HEALTHNOW NEW YORK, INC. DBA BLUESHIELD OF NORTHEASTERN NEW YORK (National Association of Insurance Commissioners NAIC id number: 55204 ) |
| Policy contract number | 00413285 |
| Policy instance | 3 |
| Insurance contract or identification number | 00413285 | | Number of Individuals Covered | 408 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $81,665 | | 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 | | Commission paid to Insurance Broker | USD $81,665 | | Insurance broker name | NIAGARA NATIONAL INC |
|
| COFINITY (National Association of Insurance Commissioners NAIC id number: ) |
| Policy contract number | H92 |
| Policy instance | 2 |
| Insurance contract or identification number | H92 | | Number of Individuals Covered | 181 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $7,633 | | Total amount of fees paid to insurance company | USD $19,565 | | 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 $3,386 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,633 | | Amount paid for insurance broker fees | 19565 | | Additional information about fees paid to insurance broker | ADMINISTRATION FEES | | Insurance broker organization code? | 3 | | Insurance broker name | BROKERAGE CNCPTS INC |
|
| EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 ) |
| Policy contract number | 00093962 |
| Policy instance | 1 |
| Insurance contract or identification number | 00093962 | | Number of Individuals Covered | 20 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $10,392 | | 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 $230,934 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $10,392 | | Insurance broker organization code? | 3 | | Insurance broker name | NIAGARA NATIONAL INC |
|
| HEALTHNOW NEW YORK, INC. DBA BLUESHIELD OF NORTHEASTERN NEW YORK (National Association of Insurance Commissioners NAIC id number: 55204 ) |
| Policy contract number | 00413362 |
| Policy instance | 4 |
| Insurance contract or identification number | 00413362 | | Number of Individuals Covered | 5 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $628 | | 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 $19,354 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $628 | | Insurance broker name | NIAGARA NATIONAL INC |
|
| EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 ) |
| Policy contract number | 00093962 |
| Policy instance | 1 |
| Insurance contract or identification number | 00093962 | | Number of Individuals Covered | 19 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $11,103 | | 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 $188,699 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $11,103 | | Insurance broker organization code? | 3 | | Insurance broker name | NIAGARA NATIONAL INC |
|
| COFINITY (National Association of Insurance Commissioners NAIC id number: ) |
| Policy contract number | H92 |
| Policy instance | 2 |
| Insurance contract or identification number | H92 | | Number of Individuals Covered | 221 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $7,702 | | Total amount of fees paid to insurance company | USD $18,945 | | 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 $3,723 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,702 | | Amount paid for insurance broker fees | 18945 | | Additional information about fees paid to insurance broker | ADMINISTRATION FEES | | Insurance broker organization code? | 3 | | Insurance broker name | BROKERAGE CNCPTS INC |
|
| HEALTHNOW NEW YORK, INC. DBA BLUESHIELD OF NORTHEASTERN NEW YORK (National Association of Insurance Commissioners NAIC id number: 55204 ) |
| Policy contract number | 00413285 |
| Policy instance | 3 |
| Insurance contract or identification number | 00413285 | | Number of Individuals Covered | 510 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $82,963 | | 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 | | Commission paid to Insurance Broker | USD $82,963 | | Insurance broker name | NIAGARA NATIONAL INC |
|
| HM LIFE INSURANCE COMPANY OF NY (National Association of Insurance Commissioners NAIC id number: 60213 ) |
| Policy contract number | 404057 |
| Policy instance | 2 |
| Insurance contract or identification number | 404057 | | Number of Individuals Covered | 197 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $57,237 | | 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 $572,369 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $57,237 | | Insurance broker organization code? | 3 | | Insurance broker name | NIAGARA NATIONAL INC |
|
| COFINITY (National Association of Insurance Commissioners NAIC id number: ) |
| Policy contract number | H92 |
| Policy instance | 3 |
| Insurance contract or identification number | H92 | | Number of Individuals Covered | 230 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $6,991 | | Total amount of fees paid to insurance company | USD $19,775 | | 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 $3,788 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,991 | | Amount paid for insurance broker fees | 19775 | | Insurance broker organization code? | 3 | | Insurance broker name | NIAGARA NATIONAL INC |
|
| EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 ) |
| Policy contract number | 00093962 |
| Policy instance | 1 |
| Insurance contract or identification number | 00093962 | | Number of Individuals Covered | 20 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $10,351 | | 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 $170,287 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $10,351 | | Insurance broker organization code? | 3 | | Insurance broker name | NIAGARA NATIONAL INC |
|
| GERBER LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70939 ) |
| Policy contract number | 9960-7961 |
| Policy instance | 2 |
| Insurance contract or identification number | 9960-7961 | | Number of Individuals Covered | 643 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2011-12-31 | | Total amount of commissions paid to insurance broker | USD $52,250 | | Total amount of fees paid to insurance company | USD $151,689 | | 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 $469,935 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| EXCELLUS BLUE CROSS/BLUE SHIELD PLAN (National Association of Insurance Commissioners NAIC id number: 55107 ) |
| Policy contract number | 00093962 |
| Policy instance | 1 |
| Insurance contract or identification number | 00093962 | | Number of Individuals Covered | 19 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2011-12-31 | | Total amount of commissions paid to insurance broker | USD $6,099 | | 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 $97,975 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| NATIONWIDE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 9960-7961 |
| Policy instance | 3 |
| Insurance contract or identification number | 9960-7961 | | Number of Individuals Covered | 690 | | Insurance policy start date | 2010-01-01 | | Insurance policy end date | 2010-12-31 | | Total amount of commissions paid to insurance broker | USD $39,405 | | Total amount of fees paid to insurance company | USD $150,092 | | 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 $330,430 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| INDEPENDENT HEALTH (National Association of Insurance Commissioners NAIC id number: 95308 ) |
| Policy contract number | 31886F |
| Policy instance | 2 |
| Insurance contract or identification number | 31886F | | Number of Individuals Covered | 0 | | 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 $35,355 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| INDEPENDENT HEALTH (National Association of Insurance Commissioners NAIC id number: 95308 ) |
| Policy contract number | 31886H |
| Policy instance | 1 |
| Insurance contract or identification number | 31886H | | Number of Individuals Covered | 0 | | 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 $40,988 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
