BRAYMAN CONSTRUCTION CORPORATION has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan BRAYMAN & COVERED AFFILIATED COMPANIES HEALTH & WELFARE BENEFIT PLAN
401k plan membership statisitcs for BRAYMAN & COVERED AFFILIATED COMPANIES HEALTH & WELFARE BENEFIT PLAN
| Measure | Date | Value |
|---|
| 2021: BRAYMAN & COVERED AFFILIATED COMPANIES HEALTH & WELFARE BENEFIT PLAN 2021 401k membership |
|---|
| Total participants, beginning-of-year | 2021-09-01 | 272 |
| Total number of active participants reported on line 7a of the Form 5500 | 2021-09-01 | 262 |
| Number of retired or separated participants receiving benefits | 2021-09-01 | 11 |
| Number of other retired or separated participants entitled to future benefits | 2021-09-01 | 0 |
| Total of all active and inactive participants | 2021-09-01 | 273 |
| 2020: BRAYMAN & COVERED AFFILIATED COMPANIES HEALTH & WELFARE BENEFIT PLAN 2020 401k membership |
|---|
| Total participants, beginning-of-year | 2020-09-01 | 241 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-09-01 | 250 |
| Number of retired or separated participants receiving benefits | 2020-09-01 | 11 |
| Number of other retired or separated participants entitled to future benefits | 2020-09-01 | 0 |
| Total of all active and inactive participants | 2020-09-01 | 261 |
| 2019: BRAYMAN & COVERED AFFILIATED COMPANIES HEALTH & WELFARE BENEFIT PLAN 2019 401k membership |
|---|
| Total participants, beginning-of-year | 2019-09-01 | 220 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-09-01 | 223 |
| Number of retired or separated participants receiving benefits | 2019-09-01 | 6 |
| Number of other retired or separated participants entitled to future benefits | 2019-09-01 | 0 |
| Total of all active and inactive participants | 2019-09-01 | 229 |
| 2018: BRAYMAN & COVERED AFFILIATED COMPANIES HEALTH & WELFARE BENEFIT PLAN 2018 401k membership |
|---|
| Total participants, beginning-of-year | 2018-09-01 | 198 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-09-01 | 202 |
| Number of retired or separated participants receiving benefits | 2018-09-01 | 1 |
| Number of other retired or separated participants entitled to future benefits | 2018-09-01 | 0 |
| Total of all active and inactive participants | 2018-09-01 | 203 |
| 2017: BRAYMAN & COVERED AFFILIATED COMPANIES HEALTH & WELFARE BENEFIT PLAN 2017 401k membership |
|---|
| Total participants, beginning-of-year | 2017-09-01 | 194 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-09-01 | 192 |
| Number of retired or separated participants receiving benefits | 2017-09-01 | 5 |
| Number of other retired or separated participants entitled to future benefits | 2017-09-01 | 0 |
| Total of all active and inactive participants | 2017-09-01 | 197 |
| 2016: BRAYMAN & COVERED AFFILIATED COMPANIES HEALTH & WELFARE BENEFIT PLAN 2016 401k membership |
|---|
| Total participants, beginning-of-year | 2016-09-01 | 207 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-09-01 | 194 |
| Number of retired or separated participants receiving benefits | 2016-09-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2016-09-01 | 0 |
| Total of all active and inactive participants | 2016-09-01 | 194 |
| 2015: BRAYMAN & COVERED AFFILIATED COMPANIES HEALTH & WELFARE BENEFIT PLAN 2015 401k membership |
|---|
| Total participants, beginning-of-year | 2015-09-01 | 214 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-09-01 | 255 |
| Number of retired or separated participants receiving benefits | 2015-09-01 | 3 |
| Number of other retired or separated participants entitled to future benefits | 2015-09-01 | 0 |
| Total of all active and inactive participants | 2015-09-01 | 258 |
| 2014: BRAYMAN & COVERED AFFILIATED COMPANIES HEALTH & WELFARE BENEFIT PLAN 2014 401k membership |
|---|
| Total participants, beginning-of-year | 2014-09-01 | 208 |
| Total number of active participants reported on line 7a of the Form 5500 | 2014-09-01 | 211 |
| Number of retired or separated participants receiving benefits | 2014-09-01 | 3 |
| Number of other retired or separated participants entitled to future benefits | 2014-09-01 | 0 |
| Total of all active and inactive participants | 2014-09-01 | 214 |
| 2013: BRAYMAN & COVERED AFFILIATED COMPANIES HEALTH & WELFARE BENEFIT PLAN 2013 401k membership |
|---|
| Total participants, beginning-of-year | 2013-09-01 | 173 |
| Total number of active participants reported on line 7a of the Form 5500 | 2013-09-01 | 234 |
| Number of retired or separated participants receiving benefits | 2013-09-01 | 6 |
| Number of other retired or separated participants entitled to future benefits | 2013-09-01 | 0 |
| Total of all active and inactive participants | 2013-09-01 | 240 |
| 2012: BRAYMAN & COVERED AFFILIATED COMPANIES HEALTH & WELFARE BENEFIT PLAN 2012 401k membership |
|---|
| Total participants, beginning-of-year | 2012-09-01 | 196 |
| Total number of active participants reported on line 7a of the Form 5500 | 2012-09-01 | 173 |
| Number of retired or separated participants receiving benefits | 2012-09-01 | 5 |
| Number of other retired or separated participants entitled to future benefits | 2012-09-01 | 0 |
| Total of all active and inactive participants | 2012-09-01 | 178 |
| 2011: BRAYMAN & COVERED AFFILIATED COMPANIES HEALTH & WELFARE BENEFIT PLAN 2011 401k membership |
|---|
| Total participants, beginning-of-year | 2011-09-01 | 202 |
| Total number of active participants reported on line 7a of the Form 5500 | 2011-09-01 | 198 |
| Number of retired or separated participants receiving benefits | 2011-09-01 | 3 |
| Number of other retired or separated participants entitled to future benefits | 2011-09-01 | 0 |
| Total of all active and inactive participants | 2011-09-01 | 201 |
| 2010: BRAYMAN & COVERED AFFILIATED COMPANIES HEALTH & WELFARE BENEFIT PLAN 2010 401k membership |
|---|
| Total participants, beginning-of-year | 2010-09-01 | 203 |
| Total number of active participants reported on line 7a of the Form 5500 | 2010-09-01 | 202 |
| Number of retired or separated participants receiving benefits | 2010-09-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2010-09-01 | 0 |
| Total of all active and inactive participants | 2010-09-01 | 202 |
| 2009: BRAYMAN & COVERED AFFILIATED COMPANIES HEALTH & WELFARE BENEFIT PLAN 2009 401k membership |
|---|
| Total participants, beginning-of-year | 2009-09-01 | 197 |
| Total number of active participants reported on line 7a of the Form 5500 | 2009-09-01 | 203 |
| Number of retired or separated participants receiving benefits | 2009-09-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2009-09-01 | 0 |
| Total of all active and inactive participants | 2009-09-01 | 203 |
| 2008: BRAYMAN & COVERED AFFILIATED COMPANIES HEALTH & WELFARE BENEFIT PLAN 2008 401k membership |
|---|
| Total participants, beginning-of-year | 2008-09-01 | 147 |
| Total number of active participants reported on line 7a of the Form 5500 | 2008-09-01 | 148 |
| Number of retired or separated participants receiving benefits | 2008-09-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2008-09-01 | 0 |
| Total of all active and inactive participants | 2008-09-01 | 148 |
| 2007: BRAYMAN & COVERED AFFILIATED COMPANIES HEALTH & WELFARE BENEFIT PLAN 2007 401k membership |
|---|
| Total participants, beginning-of-year | 2007-09-01 | 95 |
| Total number of active participants reported on line 7a of the Form 5500 | 2007-09-01 | 132 |
| Number of retired or separated participants receiving benefits | 2007-09-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2007-09-01 | 0 |
| Total of all active and inactive participants | 2007-09-01 | 132 |
| 2021: BRAYMAN & COVERED AFFILIATED COMPANIES HEALTH & WELFARE BENEFIT PLAN 2021 form 5500 responses |
|---|
| 2021-09-01 | Type of plan entity | Single employer plan |
| 2021-09-01 | Submission has been amended | No |
| 2021-09-01 | This submission is the final filing | No |
| 2021-09-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2021-09-01 | Plan is a collectively bargained plan | No |
| 2021-09-01 | Plan funding arrangement – Insurance | Yes |
| 2021-09-01 | Plan benefit arrangement – Insurance | Yes |
| 2020: BRAYMAN & COVERED AFFILIATED COMPANIES HEALTH & WELFARE BENEFIT PLAN 2020 form 5500 responses |
|---|
| 2020-09-01 | Type of plan entity | Single employer plan |
| 2020-09-01 | Submission has been amended | No |
| 2020-09-01 | This submission is the final filing | No |
| 2020-09-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2020-09-01 | Plan is a collectively bargained plan | No |
| 2020-09-01 | Plan funding arrangement – Insurance | Yes |
| 2020-09-01 | Plan benefit arrangement – Insurance | Yes |
| 2019: BRAYMAN & COVERED AFFILIATED COMPANIES HEALTH & WELFARE BENEFIT PLAN 2019 form 5500 responses |
|---|
| 2019-09-01 | Type of plan entity | Single employer plan |
| 2019-09-01 | Submission has been amended | No |
| 2019-09-01 | This submission is the final filing | No |
| 2019-09-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2019-09-01 | Plan is a collectively bargained plan | No |
| 2019-09-01 | Plan funding arrangement – Insurance | Yes |
| 2019-09-01 | Plan benefit arrangement – Insurance | Yes |
| 2018: BRAYMAN & COVERED AFFILIATED COMPANIES HEALTH & WELFARE BENEFIT PLAN 2018 form 5500 responses |
|---|
| 2018-09-01 | Type of plan entity | Single employer plan |
| 2018-09-01 | Submission has been amended | No |
| 2018-09-01 | This submission is the final filing | No |
| 2018-09-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2018-09-01 | Plan is a collectively bargained plan | No |
| 2018-09-01 | Plan funding arrangement – Insurance | Yes |
| 2018-09-01 | Plan benefit arrangement – Insurance | Yes |
| 2017: BRAYMAN & COVERED AFFILIATED COMPANIES HEALTH & WELFARE BENEFIT PLAN 2017 form 5500 responses |
|---|
| 2017-09-01 | Type of plan entity | Single employer plan |
| 2017-09-01 | Submission has been amended | No |
| 2017-09-01 | This submission is the final filing | No |
| 2017-09-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2017-09-01 | Plan is a collectively bargained plan | No |
| 2017-09-01 | Plan funding arrangement – Insurance | Yes |
| 2017-09-01 | Plan benefit arrangement – Insurance | Yes |
| 2016: BRAYMAN & COVERED AFFILIATED COMPANIES HEALTH & WELFARE BENEFIT PLAN 2016 form 5500 responses |
|---|
| 2016-09-01 | Type of plan entity | Single employer plan |
| 2016-09-01 | Submission has been amended | No |
| 2016-09-01 | This submission is the final filing | No |
| 2016-09-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2016-09-01 | Plan is a collectively bargained plan | No |
| 2016-09-01 | Plan funding arrangement – Insurance | Yes |
| 2016-09-01 | Plan benefit arrangement – Insurance | Yes |
| 2015: BRAYMAN & COVERED AFFILIATED COMPANIES HEALTH & WELFARE BENEFIT PLAN 2015 form 5500 responses |
|---|
| 2015-09-01 | Type of plan entity | Single employer plan |
| 2015-09-01 | Submission has been amended | No |
| 2015-09-01 | This submission is the final filing | No |
| 2015-09-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2015-09-01 | Plan is a collectively bargained plan | No |
| 2015-09-01 | Plan funding arrangement – Insurance | Yes |
| 2015-09-01 | Plan benefit arrangement – Insurance | Yes |
| 2014: BRAYMAN & COVERED AFFILIATED COMPANIES HEALTH & WELFARE BENEFIT PLAN 2014 form 5500 responses |
|---|
| 2014-09-01 | Type of plan entity | Single employer plan |
| 2014-09-01 | Submission has been amended | No |
| 2014-09-01 | This submission is the final filing | No |
| 2014-09-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2014-09-01 | Plan is a collectively bargained plan | No |
| 2014-09-01 | Plan funding arrangement – Insurance | Yes |
| 2014-09-01 | Plan benefit arrangement – Insurance | Yes |
| 2013: BRAYMAN & COVERED AFFILIATED COMPANIES HEALTH & WELFARE BENEFIT PLAN 2013 form 5500 responses |
|---|
| 2013-09-01 | Type of plan entity | Single employer plan |
| 2013-09-01 | Submission has been amended | No |
| 2013-09-01 | This submission is the final filing | No |
| 2013-09-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2013-09-01 | Plan is a collectively bargained plan | No |
| 2013-09-01 | Plan funding arrangement – Insurance | Yes |
| 2013-09-01 | Plan benefit arrangement – Insurance | Yes |
| 2012: BRAYMAN & COVERED AFFILIATED COMPANIES HEALTH & WELFARE BENEFIT PLAN 2012 form 5500 responses |
|---|
| 2012-09-01 | Type of plan entity | Single employer plan |
| 2012-09-01 | Submission has been amended | No |
| 2012-09-01 | This submission is the final filing | No |
| 2012-09-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2012-09-01 | Plan is a collectively bargained plan | No |
| 2012-09-01 | Plan funding arrangement – Insurance | Yes |
| 2012-09-01 | Plan benefit arrangement – Insurance | Yes |
| 2011: BRAYMAN & COVERED AFFILIATED COMPANIES HEALTH & WELFARE BENEFIT PLAN 2011 form 5500 responses |
|---|
| 2011-09-01 | Type of plan entity | Single employer plan |
| 2011-09-01 | Submission has been amended | No |
| 2011-09-01 | This submission is the final filing | No |
| 2011-09-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2011-09-01 | Plan is a collectively bargained plan | No |
| 2011-09-01 | Plan funding arrangement – Insurance | Yes |
| 2011-09-01 | Plan benefit arrangement – Insurance | Yes |
| 2010: BRAYMAN & COVERED AFFILIATED COMPANIES HEALTH & WELFARE BENEFIT PLAN 2010 form 5500 responses |
|---|
| 2010-09-01 | Type of plan entity | Single employer plan |
| 2010-09-01 | Submission has been amended | No |
| 2010-09-01 | This submission is the final filing | No |
| 2010-09-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2010-09-01 | Plan is a collectively bargained plan | No |
| 2010-09-01 | Plan funding arrangement – Insurance | Yes |
| 2010-09-01 | Plan benefit arrangement – Insurance | Yes |
| 2009: BRAYMAN & COVERED AFFILIATED COMPANIES HEALTH & WELFARE BENEFIT PLAN 2009 form 5500 responses |
|---|
| 2009-09-01 | Type of plan entity | Single employer plan |
| 2009-09-01 | Submission has been amended | No |
| 2009-09-01 | This submission is the final filing | No |
| 2009-09-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2009-09-01 | Plan is a collectively bargained plan | No |
| 2009-09-01 | Plan funding arrangement – Insurance | Yes |
| 2009-09-01 | Plan benefit arrangement – Insurance | Yes |
| 2008: BRAYMAN & COVERED AFFILIATED COMPANIES HEALTH & WELFARE BENEFIT PLAN 2008 form 5500 responses |
|---|
| 2008-09-01 | Type of plan entity | Single employer plan |
| 2008-09-01 | Submission has been amended | No |
| 2008-09-01 | This submission is the final filing | No |
| 2008-09-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2008-09-01 | Plan is a collectively bargained plan | No |
| 2008-09-01 | Plan funding arrangement – Insurance | Yes |
| 2008-09-01 | Plan benefit arrangement – Insurance | Yes |
| 2007: BRAYMAN & COVERED AFFILIATED COMPANIES HEALTH & WELFARE BENEFIT PLAN 2007 form 5500 responses |
|---|
| 2007-09-01 | Type of plan entity | Single employer plan |
| 2007-09-01 | First time form 5500 has been submitted | Yes |
| 2007-09-01 | Submission has been amended | No |
| 2007-09-01 | This submission is the final filing | No |
| 2007-09-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2007-09-01 | Plan is a collectively bargained plan | No |
| 2007-09-01 | Plan funding arrangement – Insurance | Yes |
| 2007-09-01 | Plan benefit arrangement – Insurance | Yes |
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUDF0AXHC |
| Policy instance | 7 |
| Insurance contract or identification number | GUDF0AXHC | | Number of Individuals Covered | 0 | | Insurance policy start date | 2021-09-01 | | Insurance policy end date | 2022-08-31 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENT | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $-126 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLTD0AXHC |
| Policy instance | 1 |
| Insurance contract or identification number | GLTD0AXHC | | Number of Individuals Covered | 348 | | Insurance policy start date | 2021-09-01 | | Insurance policy end date | 2022-08-31 | | Total amount of commissions paid to insurance broker | USD $4,185 | | Total amount of fees paid to insurance company | USD $3,646 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $57,386 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,185 | | Amount paid for insurance broker fees | 3646 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUC0AXHC |
| Policy instance | 2 |
| Insurance contract or identification number | GUC0AXHC | | Number of Individuals Covered | 141 | | Insurance policy start date | 2021-09-01 | | Insurance policy end date | 2022-08-31 | | Total amount of commissions paid to insurance broker | USD $11,297 | | Total amount of fees paid to insurance company | USD $4,521 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $75,315 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $11,297 | | Amount paid for insurance broker fees | 4521 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GVTL0AXHC |
| Policy instance | 3 |
| Insurance contract or identification number | GVTL0AXHC | | Number of Individuals Covered | 131 | | Insurance policy start date | 2021-09-01 | | Insurance policy end date | 2022-08-31 | | Total amount of commissions paid to insurance broker | USD $8,499 | | Total amount of fees paid to insurance company | USD $3,269 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $56,662 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,499 | | Amount paid for insurance broker fees | 3269 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| VISION BENEFITS OF AMERICA (National Association of Insurance Commissioners NAIC id number: 53953 ) |
| Policy contract number | 3645 |
| Policy instance | 4 |
| Insurance contract or identification number | 3645 | | Number of Individuals Covered | 225 | | Insurance policy start date | 2021-09-01 | | Insurance policy end date | 2022-08-31 | | Total amount of commissions paid to insurance broker | USD $1,233 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $0 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,233 | | Insurance broker organization code? | 3 |
|
| HIGHMARK BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 54771 ) |
| Policy contract number | 269814 |
| Policy instance | 5 |
| Insurance contract or identification number | 269814 | | Number of Individuals Covered | 591 | | Insurance policy start date | 2021-09-01 | | Insurance policy end date | 2022-08-31 | | Total amount of commissions paid to insurance broker | USD $47,711 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $1,527,180 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $47,711 | | Insurance broker organization code? | 3 |
|
| HIGHMARK BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 54771 ) |
| Policy contract number | 269814 |
| Policy instance | 6 |
| Insurance contract or identification number | 269814 | | Number of Individuals Covered | 553 | | Insurance policy start date | 2021-09-01 | | Insurance policy end date | 2022-08-31 | | Total amount of commissions paid to insurance broker | USD $12,331 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $113,977 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $12,331 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLTD0AXHC |
| Policy instance | 1 |
| Insurance contract or identification number | GLTD0AXHC | | Number of Individuals Covered | 328 | | Insurance policy start date | 2020-09-01 | | Insurance policy end date | 2021-08-31 | | Total amount of commissions paid to insurance broker | USD $4,531 | | Total amount of fees paid to insurance company | USD $3,745 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $71,235 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,531 | | Amount paid for insurance broker fees | 3745 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUC0AXHC |
| Policy instance | 2 |
| Insurance contract or identification number | GUC0AXHC | | Number of Individuals Covered | 121 | | Insurance policy start date | 2020-09-01 | | Insurance policy end date | 2021-08-31 | | Total amount of commissions paid to insurance broker | USD $12,749 | | Total amount of fees paid to insurance company | USD $4,094 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $84,990 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $12,749 | | Amount paid for insurance broker fees | 4094 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GVTL0AXHC |
| Policy instance | 3 |
| Insurance contract or identification number | GVTL0AXHC | | Number of Individuals Covered | 123 | | Insurance policy start date | 2020-09-01 | | Insurance policy end date | 2021-08-31 | | Total amount of commissions paid to insurance broker | USD $9,202 | | Total amount of fees paid to insurance company | USD $2,866 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $61,350 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $9,202 | | Amount paid for insurance broker fees | 2866 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| HIGHMARK BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 54771 ) |
| Policy contract number | 269814 |
| Policy instance | 5 |
| Insurance contract or identification number | 269814 | | Number of Individuals Covered | 509 | | Insurance policy start date | 2020-09-01 | | Insurance policy end date | 2021-08-31 | | Total amount of commissions paid to insurance broker | USD $38,643 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $1,104,663 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $38,643 | | Insurance broker organization code? | 3 |
|
| HIGHMARK BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 54771 ) |
| Policy contract number | 269814 |
| Policy instance | 6 |
| Insurance contract or identification number | 269814 | | Number of Individuals Covered | 476 | | Insurance policy start date | 2020-09-01 | | Insurance policy end date | 2021-08-31 | | Total amount of commissions paid to insurance broker | USD $10,926 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $90,514 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $10,926 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUDF0AXHC |
| Policy instance | 7 |
| Insurance contract or identification number | GUDF0AXHC | | Number of Individuals Covered | 203 | | Insurance policy start date | 2020-09-01 | | Insurance policy end date | 2021-08-31 | | Total amount of commissions paid to insurance broker | USD $5,233 | | Total amount of fees paid to insurance company | USD $321 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENT | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $34,890 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,233 | | Amount paid for insurance broker fees | 321 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| VISION BENEFITS OF AMERICA (National Association of Insurance Commissioners NAIC id number: 53953 ) |
| Policy contract number | 3645 |
| Policy instance | 4 |
| Insurance contract or identification number | 3645 | | Number of Individuals Covered | 216 | | Insurance policy start date | 2020-09-01 | | Insurance policy end date | 2021-08-31 | | Total amount of commissions paid to insurance broker | USD $1,135 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,135 | | Insurance broker organization code? | 3 |
|
| UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 ) |
| Policy contract number | VARIOUS |
| Policy instance | 5 |
| Insurance contract or identification number | VARIOUS | | Number of Individuals Covered | 473 | | Insurance policy start date | 2019-09-01 | | Insurance policy end date | 2020-08-31 | | Total amount of commissions paid to insurance broker | USD $36,132 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $1,205,600 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $36,132 | | Insurance broker organization code? | 3 |
|
| VISION BENEFITS OF AMERICA (National Association of Insurance Commissioners NAIC id number: 53953 ) |
| Policy contract number | 3645 |
| Policy instance | 4 |
| Insurance contract or identification number | 3645 | | Number of Individuals Covered | 197 | | Insurance policy start date | 2019-09-01 | | Insurance policy end date | 2020-08-31 | | Total amount of commissions paid to insurance broker | USD $1,022 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,022 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GVTL0AXHC |
| Policy instance | 3 |
| Insurance contract or identification number | GVTL0AXHC | | Number of Individuals Covered | 115 | | Insurance policy start date | 2019-09-01 | | Insurance policy end date | 2020-08-31 | | Total amount of commissions paid to insurance broker | USD $7,213 | | Total amount of fees paid to insurance company | USD $1,942 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $48,087 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,213 | | Amount paid for insurance broker fees | 1942 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUC0AXHC |
| Policy instance | 2 |
| Insurance contract or identification number | GUC0AXHC | | Number of Individuals Covered | 107 | | Insurance policy start date | 2019-09-01 | | Insurance policy end date | 2020-08-31 | | Total amount of commissions paid to insurance broker | USD $10,530 | | Total amount of fees paid to insurance company | USD $2,476 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $70,202 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $10,530 | | Amount paid for insurance broker fees | 2476 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLTD0AXHC |
| Policy instance | 1 |
| Insurance contract or identification number | GLTD0AXHC | | Number of Individuals Covered | 320 | | Insurance policy start date | 2019-09-01 | | Insurance policy end date | 2020-08-31 | | Total amount of commissions paid to insurance broker | USD $4,455 | | Total amount of fees paid to insurance company | USD $2,706 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $68,208 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,455 | | Amount paid for insurance broker fees | 2706 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| UPMC HEALTH BENEFITS (National Association of Insurance Commissioners NAIC id number: 11018 ) |
| Policy contract number | VARIOUS |
| Policy instance | 6 |
| Insurance contract or identification number | VARIOUS | | Number of Individuals Covered | 419 | | Insurance policy start date | 2019-09-01 | | Insurance policy end date | 2020-08-31 | | Total amount of commissions paid to insurance broker | USD $9,985 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $90,837 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $9,985 | | Insurance broker organization code? | 3 |
|
| VISION BENEFITS OF AMERICA (National Association of Insurance Commissioners NAIC id number: 53953 ) |
| Policy contract number | 3645 |
| Policy instance | 4 |
| Insurance contract or identification number | 3645 | | Number of Individuals Covered | 163 | | Insurance policy start date | 2018-09-01 | | Insurance policy end date | 2019-08-31 | | Total amount of commissions paid to insurance broker | USD $899 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $899 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUC0AXHC |
| Policy instance | 2 |
| Insurance contract or identification number | GUC0AXHC | | Number of Individuals Covered | 70 | | Insurance policy start date | 2018-09-01 | | Insurance policy end date | 2019-08-31 | | Total amount of commissions paid to insurance broker | USD $6,495 | | Total amount of fees paid to insurance company | USD $2,379 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $43,301 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,495 | | Amount paid for insurance broker fees | 2379 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| UPMC HEALTH BENEFITS (National Association of Insurance Commissioners NAIC id number: 11018 ) |
| Policy contract number | VARIOUS |
| Policy instance | 6 |
| Insurance contract or identification number | VARIOUS | | Number of Individuals Covered | 362 | | Insurance policy start date | 2018-09-01 | | Insurance policy end date | 2019-08-31 | | Total amount of commissions paid to insurance broker | USD $8,383 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $84,191 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,383 | | Insurance broker organization code? | 3 |
|
| UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 ) |
| Policy contract number | VARIOUS |
| Policy instance | 5 |
| Insurance contract or identification number | VARIOUS | | Number of Individuals Covered | 419 | | Insurance policy start date | 2018-09-01 | | Insurance policy end date | 2019-08-31 | | Total amount of commissions paid to insurance broker | USD $36,816 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $1,230,159 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $36,816 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GVTL0AXHC |
| Policy instance | 3 |
| Insurance contract or identification number | GVTL0AXHC | | Number of Individuals Covered | 98 | | Insurance policy start date | 2018-09-01 | | Insurance policy end date | 2019-08-31 | | Total amount of commissions paid to insurance broker | USD $5,787 | | Total amount of fees paid to insurance company | USD $2,021 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $38,577 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,787 | | Amount paid for insurance broker fees | 2021 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLTD0AXHC |
| Policy instance | 1 |
| Insurance contract or identification number | GLTD0AXHC | | Number of Individuals Covered | 273 | | Insurance policy start date | 2018-09-01 | | Insurance policy end date | 2019-08-31 | | Total amount of commissions paid to insurance broker | USD $4,085 | | Total amount of fees paid to insurance company | USD $3,090 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $53,390 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,085 | | Amount paid for insurance broker fees | 3090 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 ) |
| Policy contract number | VARIOUS |
| Policy instance | 5 |
| Insurance contract or identification number | VARIOUS | | Number of Individuals Covered | 414 | | Insurance policy start date | 2017-09-01 | | Insurance policy end date | 2018-08-31 | | Total amount of commissions paid to insurance broker | USD $40,844 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $1,347,700 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| UPMC HEALTH BENEFITS (National Association of Insurance Commissioners NAIC id number: 11018 ) |
| Policy contract number | VARIOUS |
| Policy instance | 6 |
| Insurance contract or identification number | VARIOUS | | Number of Individuals Covered | 364 | | Insurance policy start date | 2017-09-01 | | Insurance policy end date | 2018-08-31 | | Total amount of commissions paid to insurance broker | USD $7,638 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $77,218 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLTD0AXHC |
| Policy instance | 1 |
| Insurance contract or identification number | GLTD0AXHC | | Number of Individuals Covered | 246 | | Insurance policy start date | 2017-09-01 | | Insurance policy end date | 2018-08-31 | | Total amount of commissions paid to insurance broker | USD $4,028 | | Total amount of fees paid to insurance company | USD $1,190 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $51,127 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUC0AXHC |
| Policy instance | 2 |
| Insurance contract or identification number | GUC0AXHC | | Number of Individuals Covered | 57 | | Insurance policy start date | 2017-09-01 | | Insurance policy end date | 2018-08-31 | | Total amount of commissions paid to insurance broker | USD $5,708 | | Total amount of fees paid to insurance company | USD $821 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $38,056 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GVTL0AXHC |
| Policy instance | 3 |
| Insurance contract or identification number | GVTL0AXHC | | Number of Individuals Covered | 83 | | Insurance policy start date | 2017-09-01 | | Insurance policy end date | 2018-08-31 | | Total amount of commissions paid to insurance broker | USD $4,917 | | Total amount of fees paid to insurance company | USD $764 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $32,781 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| VISION BENEFITS OF AMERICA (National Association of Insurance Commissioners NAIC id number: 53953 ) |
| Policy contract number | 3645 |
| Policy instance | 4 |
| Insurance contract or identification number | 3645 | | Number of Individuals Covered | 152 | | Insurance policy start date | 2017-09-01 | | Insurance policy end date | 2018-08-31 | | Total amount of commissions paid to insurance broker | USD $977 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| VISION BENEFITS OF AMERICA (National Association of Insurance Commissioners NAIC id number: 53953 ) |
| Policy contract number | 3645 |
| Policy instance | 6 |
| Insurance contract or identification number | 3645 | | Number of Individuals Covered | 158 | | Insurance policy start date | 2015-09-01 | | Insurance policy end date | 2016-08-31 | | Total amount of commissions paid to insurance broker | USD $897 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $897 | | Insurance broker organization code? | 3 | | Insurance broker name | HENDERSON BROTHERS, INC. |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GVTL0AXHC |
| Policy instance | 5 |
| Insurance contract or identification number | GVTL0AXHC | | Number of Individuals Covered | 76 | | Insurance policy start date | 2015-09-01 | | Insurance policy end date | 2016-08-31 | | Total amount of commissions paid to insurance broker | USD $4,270 | | Total amount of fees paid to insurance company | USD $258 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $28,470 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,270 | | Amount paid for insurance broker fees | 258 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | HENDERSON BROTHERS, INC. |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUC0AXHC |
| Policy instance | 4 |
| Insurance contract or identification number | GUC0AXHC | | Number of Individuals Covered | 55 | | Insurance policy start date | 2015-09-01 | | Insurance policy end date | 2016-08-31 | | Total amount of commissions paid to insurance broker | USD $4,364 | | Total amount of fees paid to insurance company | USD $240 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $29,091 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,364 | | Amount paid for insurance broker fees | 240 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | HENDERSON BROTHERS, INC. |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLTD0AXHC |
| Policy instance | 3 |
| Insurance contract or identification number | GLTD0AXHC | | Number of Individuals Covered | 258 | | Insurance policy start date | 2015-09-01 | | Insurance policy end date | 2016-08-31 | | Total amount of commissions paid to insurance broker | USD $3,719 | | Total amount of fees paid to insurance company | USD $361 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $44,371 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,719 | | Amount paid for insurance broker fees | 361 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | HENDERSON BROTHERS, INC. |
|
| UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 ) |
| Policy contract number | VARIOUS |
| Policy instance | 2 |
| Insurance contract or identification number | VARIOUS | | Number of Individuals Covered | 420 | | Insurance policy start date | 2015-09-01 | | Insurance policy end date | 2016-08-31 | | Total amount of commissions paid to insurance broker | USD $46,880 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $1,437,496 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $46,880 | | Insurance broker organization code? | 3 | | Insurance broker name | HENDERSON BROTHERS, INC. |
|
| UPMC HEALTH BENEFITS (National Association of Insurance Commissioners NAIC id number: 11018 ) |
| Policy contract number | VARIOUS |
| Policy instance | 1 |
| Insurance contract or identification number | VARIOUS | | Number of Individuals Covered | 356 | | Insurance policy start date | 2015-09-01 | | Insurance policy end date | 2016-08-31 | | Total amount of commissions paid to insurance broker | USD $7,477 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $72,225 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,477 | | Insurance broker organization code? | 3 | | Insurance broker name | HENDERSON BROTHERS, INC. |
|
| UPMC HEALTH BENEFITS (National Association of Insurance Commissioners NAIC id number: 11018 ) |
| Policy contract number | VARIOUS |
| Policy instance | 1 |
| Insurance contract or identification number | VARIOUS | | Number of Individuals Covered | 323 | | Insurance policy start date | 2014-09-01 | | Insurance policy end date | 2015-08-31 | | Total amount of commissions paid to insurance broker | USD $6,098 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $57,970 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,098 | | Insurance broker organization code? | 3 | | Insurance broker name | HENDERSON BROTHERS, INC. |
|
| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | 000010030175 |
| Policy instance | 3 |
| Insurance contract or identification number | 000010030175 | | Number of Individuals Covered | 214 | | Insurance policy start date | 2014-09-01 | | Insurance policy end date | 2015-08-31 | | Total amount of commissions paid to insurance broker | USD $4,272 | | Total amount of fees paid to insurance company | USD $1,515 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $49,525 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,272 | | Amount paid for insurance broker fees | 1515 | | Additional information about fees paid to insurance broker | BROKER BONUS | | Insurance broker organization code? | 3 | | Insurance broker name | HENDERSON BROTHERS, INC. |
|
| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | 10179749 |
| Policy instance | 4 |
| Insurance contract or identification number | 10179749 | | Number of Individuals Covered | 41 | | Insurance policy start date | 2014-09-01 | | Insurance policy end date | 2015-08-31 | | Total amount of commissions paid to insurance broker | USD $3,887 | | Total amount of fees paid to insurance company | USD $687 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $25,916 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,887 | | Amount paid for insurance broker fees | 687 | | Additional information about fees paid to insurance broker | BROKER BONUS | | Insurance broker organization code? | 3 | | Insurance broker name | HENDERSON BROTHERS, INC. |
|
| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | 400001000 |
| Policy instance | 5 |
| Insurance contract or identification number | 400001000 | | Number of Individuals Covered | 69 | | Insurance policy start date | 2014-09-01 | | Insurance policy end date | 2015-08-31 | | Total amount of commissions paid to insurance broker | USD $4,241 | | Total amount of fees paid to insurance company | USD $642 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $28,269 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,241 | | Amount paid for insurance broker fees | 642 | | Additional information about fees paid to insurance broker | BROKER BONUS | | Insurance broker organization code? | 3 | | Insurance broker name | HENDERSON BROTHERS, INC. |
|
| VISION BENEFITS OF AMERICA (National Association of Insurance Commissioners NAIC id number: 53953 ) |
| Policy contract number | 3645 |
| Policy instance | 6 |
| Insurance contract or identification number | 3645 | | Number of Individuals Covered | 91 | | Insurance policy start date | 2014-09-01 | | Insurance policy end date | 2015-08-31 | | Total amount of commissions paid to insurance broker | USD $567 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $567 | | Insurance broker organization code? | 3 | | Insurance broker name | HENDERSON BROTHERS, INC. |
|
| UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 ) |
| Policy contract number | VARIOUS |
| Policy instance | 2 |
| Insurance contract or identification number | VARIOUS | | Number of Individuals Covered | 370 | | Insurance policy start date | 2014-09-01 | | Insurance policy end date | 2015-08-31 | | Total amount of commissions paid to insurance broker | USD $48,448 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $1,407,565 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $48,448 | | Insurance broker organization code? | 3 | | Insurance broker name | HENDERSON BROTHERS, INC. |
|
| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | 000010030175 |
| Policy instance | 3 |
| Insurance contract or identification number | 000010030175 | | Number of Individuals Covered | 208 | | Insurance policy start date | 2013-09-01 | | Insurance policy end date | 2014-08-31 | | Total amount of commissions paid to insurance broker | USD $4,291 | | Total amount of fees paid to insurance company | USD $1,484 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $45,864 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,291 | | Amount paid for insurance broker fees | 1484 | | Additional information about fees paid to insurance broker | BROKER BONUS | | Insurance broker organization code? | 3 | | Insurance broker name | HENDERSON BROTHERS, INC. |
|
| UPMC HEALTH BENEFITS (National Association of Insurance Commissioners NAIC id number: 11018 ) |
| Policy contract number | VARIOUS |
| Policy instance | 1 |
| Insurance contract or identification number | VARIOUS | | Number of Individuals Covered | 350 | | Insurance policy start date | 2013-09-01 | | Insurance policy end date | 2014-08-31 | | Total amount of commissions paid to insurance broker | USD $6,519 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $76,348 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,519 | | Insurance broker organization code? | 3 | | Insurance broker name | HENDERSON BROTHERS, INC. |
|
| UPMC HEALTH OPTIONS (National Association of Insurance Commissioners NAIC id number: 15345 ) |
| Policy contract number | VARIOUS |
| Policy instance | 2 |
| Insurance contract or identification number | VARIOUS | | Number of Individuals Covered | 433 | | Insurance policy start date | 2013-09-01 | | Insurance policy end date | 2014-08-31 | | Total amount of commissions paid to insurance broker | USD $32,273 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $1,413,076 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $32,273 | | Insurance broker organization code? | 3 | | Insurance broker name | HENDERSON BROTHERS, INC. |
|
| HIGHMARK BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 54771 ) |
| Policy contract number | 063941 |
| Policy instance | 2 |
| Insurance contract or identification number | 063941 | | Number of Individuals Covered | 568 | | Insurance policy start date | 2012-09-01 | | Insurance policy end date | 2013-08-31 | | Total amount of commissions paid to insurance broker | USD $5,182 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $173,346 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,182 | | Insurance broker organization code? | 3 | | Insurance broker name | HENDERSON BROTHERS, INC. |
|
| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | 000010030175 |
| Policy instance | 3 |
| Insurance contract or identification number | 000010030175 | | Number of Individuals Covered | 196 | | Insurance policy start date | 2011-10-01 | | Insurance policy end date | 2012-09-30 | | Total amount of commissions paid to insurance broker | USD $4,028 | | Total amount of fees paid to insurance company | USD $2,929 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $40,560 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,028 | | Amount paid for insurance broker fees | 2784 | | Additional information about fees paid to insurance broker | BROKER BONUS | | Insurance broker organization code? | 3 | | Insurance broker name | BENEFIT ADVISORS NETWORK, LLC |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 218981 |
| Policy instance | 4 |
| Insurance contract or identification number | 218981 | | Number of Individuals Covered | 125 | | Insurance policy start date | 2012-09-01 | | Insurance policy end date | 2013-08-31 | | Total amount of commissions paid to insurance broker | USD $2,945 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $52,981 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,945 | | Insurance broker organization code? | 3 | | Insurance broker name | HENDERSON BROTHERS INC |
|
| HIGHMARK BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 54771 ) |
| Policy contract number | 063941 |
| Policy instance | 1 |
| Insurance contract or identification number | 063941 | | Number of Individuals Covered | 568 | | Insurance policy start date | 2012-09-01 | | Insurance policy end date | 2013-08-31 | | Total amount of commissions paid to insurance broker | USD $35,233 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $1,171,950 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $35,233 | | Insurance broker organization code? | 3 | | Insurance broker name | HENDERSON BROTHERS, INC. |
|
| SUN LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80926 ) |
| Policy contract number | 041-7459-00 |
| Policy instance | 4 |
| Insurance contract or identification number | 041-7459-00 | | Number of Individuals Covered | 107 | | Insurance policy start date | 2011-09-01 | | Insurance policy end date | 2011-09-30 | | Total amount of commissions paid to insurance broker | USD $226 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $3,298 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $226 | | Insurance broker organization code? | 3 | | Insurance broker name | HENDERSON BROTHERS INC |
|
| HIGHMARK BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 54771 ) |
| Policy contract number | 04785704 |
| Policy instance | 2 |
| Insurance contract or identification number | 04785704 | | Number of Individuals Covered | 407 | | Insurance policy start date | 2011-09-01 | | Insurance policy end date | 2012-08-31 | | Total amount of commissions paid to insurance broker | USD $5,313 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $177,239 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,313 | | Insurance broker organization code? | 3 | | Insurance broker name | HENDERSON BROTHERS, INC. |
|
| HIGHMARK BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 54771 ) |
| Policy contract number | 04785704 |
| Policy instance | 1 |
| Insurance contract or identification number | 04785704 | | Number of Individuals Covered | 407 | | Insurance policy start date | 2011-09-01 | | Insurance policy end date | 2012-08-31 | | Total amount of commissions paid to insurance broker | USD $37,212 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $1,224,392 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $36,704 | | Insurance broker organization code? | 3 | | Insurance broker name | COURY HEALTH SERVICES, INC. |
|
| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | 000010030175 |
| Policy instance | 3 |
| Insurance contract or identification number | 000010030175 | | Number of Individuals Covered | 202 | | Insurance policy start date | 2010-10-01 | | Insurance policy end date | 2011-09-30 | | Total amount of commissions paid to insurance broker | USD $4,290 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $45,799 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,082 | | Insurance broker organization code? | 3 | | Insurance broker name | HENDERSON BROTHERS, INC. |
|
| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
| Policy contract number | TM05599385 |
| Policy instance | 1 |
| Insurance contract or identification number | TM05599385 | | Number of Individuals Covered | 0 | | Insurance policy start date | 2010-09-01 | | Insurance policy end date | 2011-08-31 | | Total amount of commissions paid to insurance broker | USD $173 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $-224 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $173 | | Insurance broker organization code? | 3 | | Insurance broker name | COURY HEALTH SERVICES, INC. |
|
| HIGHMARK BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 54771 ) |
| Policy contract number | 04785704 |
| Policy instance | 2 |
| Insurance contract or identification number | 04785704 | | Number of Individuals Covered | 395 | | Insurance policy start date | 2010-09-01 | | Insurance policy end date | 2011-08-31 | | Total amount of commissions paid to insurance broker | USD $39,549 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $1,283,737 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $39,549 | | Insurance broker organization code? | 3 | | Insurance broker name | COURY HEALTH SERVICES, INC. |
|
| HIGHMARK BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 54771 ) |
| Policy contract number | 04785704 |
| Policy instance | 3 |
| Insurance contract or identification number | 04785704 | | Number of Individuals Covered | 395 | | Insurance policy start date | 2010-09-01 | | Insurance policy end date | 2011-08-31 | | Total amount of commissions paid to insurance broker | USD $5,595 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $185,798 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,595 | | Insurance broker organization code? | 3 | | Insurance broker name | COURY HEALTH SERVICES, INC. |
|
| SUN LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80926 ) |
| Policy contract number | 041-7459-00 |
| Policy instance | 5 |
| Insurance contract or identification number | 041-7459-00 | | Number of Individuals Covered | 107 | | Insurance policy start date | 2010-09-01 | | Insurance policy end date | 2011-08-31 | | Total amount of commissions paid to insurance broker | USD $2,615 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $42,180 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,516 | | Insurance broker organization code? | 3 | | Insurance broker name | HENDERSON BROTHERS INC |
|
| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | 000010030175 |
| Policy instance | 4 |
| Insurance contract or identification number | 000010030175 | | Number of Individuals Covered | 203 | | Insurance policy start date | 2009-10-01 | | Insurance policy end date | 2010-09-30 | | Total amount of commissions paid to insurance broker | USD $5,151 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $64,657 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,151 | | Insurance broker organization code? | 3 | | Insurance broker name | COURY HEALTH SERVICES, INC. |
|
| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | 000010030175 |
| Policy instance | 4 |
| Insurance contract or identification number | 000010030175 | | Number of Individuals Covered | 197 | | Insurance policy start date | 2008-10-01 | | Insurance policy end date | 2009-09-30 | | Total amount of commissions paid to insurance broker | USD $3,884 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $37,686 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,884 | | Insurance broker organization code? | 3 | | Insurance broker name | COURY HEALTH SERVICES, INC. |
|
| HIGHMARK BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 54771 ) |
| Policy contract number | 04785704 |
| Policy instance | 3 |
| Insurance contract or identification number | 04785704 | | Number of Individuals Covered | 388 | | Insurance policy start date | 2009-09-01 | | Insurance policy end date | 2010-08-31 | | Total amount of commissions paid to insurance broker | USD $5,913 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $262,197 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,913 | | Insurance broker organization code? | 3 | | Insurance broker name | COURY HEALTH SERVICES, INC. |
|
| HIGHMARK BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 54771 ) |
| Policy contract number | 04785704 |
| Policy instance | 2 |
| Insurance contract or identification number | 04785704 | | Number of Individuals Covered | 388 | | Insurance policy start date | 2009-09-01 | | Insurance policy end date | 2010-08-31 | | Total amount of commissions paid to insurance broker | USD $26,039 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $1,154,741 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $26,039 | | Insurance broker organization code? | 3 | | Insurance broker name | COURY HEALTH SERVICES, INC. |
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| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
| Policy contract number | TM05599385 |
| Policy instance | 1 |
| Insurance contract or identification number | TM05599385 | | Number of Individuals Covered | 377 | | Insurance policy start date | 2009-09-01 | | Insurance policy end date | 2010-08-31 | | Total amount of commissions paid to insurance broker | USD $2,766 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $54,834 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,766 | | Insurance broker organization code? | 3 | | Insurance broker name | COURY HEALTH SERVICES, INC. |
|
| HIGHMARK BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 54771 ) |
| Policy contract number | 04785704 |
| Policy instance | 2 |
| Insurance contract or identification number | 04785704 | | Number of Individuals Covered | 398 | | Insurance policy start date | 2008-09-01 | | Insurance policy end date | 2009-08-31 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $866,393 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
| Policy contract number | TM05599385 |
| Policy instance | 1 |
| Insurance contract or identification number | TM05599385 | | Number of Individuals Covered | 342 | | Insurance policy start date | 2008-09-01 | | Insurance policy end date | 2009-08-31 | | Total amount of commissions paid to insurance broker | USD $2,317 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $40,602 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,317 | | Insurance broker organization code? | 3 | | Insurance broker name | COURY HEALTH SERVICES, INC. |
|
| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | 000010030175 |
| Policy instance | 4 |
| Insurance contract or identification number | 000010030175 | | Number of Individuals Covered | 147 | | Insurance policy start date | 2007-10-01 | | Insurance policy end date | 2008-09-30 | | Total amount of commissions paid to insurance broker | USD $3,522 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $30,432 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,522 | | Insurance broker organization code? | 3 | | Insurance broker name | COURY HEALTH SERVICES, INC. |
|
| HIGHMARK BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 54771 ) |
| Policy contract number | 04785704 |
| Policy instance | 3 |
| Insurance contract or identification number | 04785704 | | Number of Individuals Covered | 398 | | Insurance policy start date | 2008-09-01 | | Insurance policy end date | 2009-08-31 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $196,705 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HIGHMARK BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 54771 ) |
| Policy contract number | 04785704 |
| Policy instance | 2 |
| Insurance contract or identification number | 04785704 | | Number of Individuals Covered | 296 | | Insurance policy start date | 2007-09-01 | | Insurance policy end date | 2008-08-31 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $653,167 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
| Policy contract number | TM05599385 |
| Policy instance | 1 |
| Insurance contract or identification number | TM05599385 | | Number of Individuals Covered | 210 | | Insurance policy start date | 2007-09-01 | | Insurance policy end date | 2008-08-31 | | Total amount of commissions paid to insurance broker | USD $1,728 | | Total amount of fees paid to insurance company | USD $304 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $27,500 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,728 | | Amount paid for insurance broker fees | 304 | | Additional information about fees paid to insurance broker | PREFERRED BROKER COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | COURY HEALTH SERVICES, INC. |
|
| HIGHMARK BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 54771 ) |
| Policy contract number | 04785704 |
| Policy instance | 3 |
| Insurance contract or identification number | 04785704 | | Number of Individuals Covered | 296 | | Insurance policy start date | 2007-09-01 | | Insurance policy end date | 2008-08-31 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $146,781 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
