THE BRIAR TEAM, LLC has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan THE BRIAR TEAM, LLC WELFARE BENEFITS PLAN
| Measure | Date | Value |
|---|
| 2022: THE BRIAR TEAM, LLC WELFARE BENEFITS PLAN 2022 401k membership |
|---|
| Total participants, beginning-of-year | 2022-01-01 | 171 |
| Total number of active participants reported on line 7a of the Form 5500 | 2022-01-01 | 173 |
| Number of retired or separated participants receiving benefits | 2022-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2022-01-01 | 0 |
| Total of all active and inactive participants | 2022-01-01 | 173 |
| 2021: THE BRIAR TEAM, LLC WELFARE BENEFITS PLAN 2021 401k membership |
|---|
| Total participants, beginning-of-year | 2021-12-01 | 173 |
| Total number of active participants reported on line 7a of the Form 5500 | 2021-12-01 | 171 |
| Number of retired or separated participants receiving benefits | 2021-12-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2021-12-01 | 0 |
| Total of all active and inactive participants | 2021-12-01 | 171 |
| 2020: THE BRIAR TEAM, LLC WELFARE BENEFITS PLAN 2020 401k membership |
|---|
| Total participants, beginning-of-year | 2020-12-01 | 171 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-12-01 | 172 |
| Number of retired or separated participants receiving benefits | 2020-12-01 | 1 |
| Number of other retired or separated participants entitled to future benefits | 2020-12-01 | 0 |
| Total of all active and inactive participants | 2020-12-01 | 173 |
| 2019: THE BRIAR TEAM, LLC WELFARE BENEFITS PLAN 2019 401k membership |
|---|
| Total participants, beginning-of-year | 2019-12-01 | 191 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-12-01 | 171 |
| Number of retired or separated participants receiving benefits | 2019-12-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2019-12-01 | 0 |
| Total of all active and inactive participants | 2019-12-01 | 171 |
| 2018: THE BRIAR TEAM, LLC WELFARE BENEFITS PLAN 2018 401k membership |
|---|
| Total participants, beginning-of-year | 2018-12-01 | 152 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-12-01 | 176 |
| Number of retired or separated participants receiving benefits | 2018-12-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2018-12-01 | 0 |
| Total of all active and inactive participants | 2018-12-01 | 176 |
| 2017: THE BRIAR TEAM, LLC WELFARE BENEFITS PLAN 2017 401k membership |
|---|
| Total participants, beginning-of-year | 2017-12-01 | 175 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-12-01 | 183 |
| Number of retired or separated participants receiving benefits | 2017-12-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2017-12-01 | 0 |
| Total of all active and inactive participants | 2017-12-01 | 183 |
| Total participants, beginning-of-year | 2017-02-01 | 137 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-02-01 | 175 |
| Number of retired or separated participants receiving benefits | 2017-02-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2017-02-01 | 0 |
| Total of all active and inactive participants | 2017-02-01 | 175 |
| 2016: THE BRIAR TEAM, LLC WELFARE BENEFITS PLAN 2016 401k membership |
|---|
| Total participants, beginning-of-year | 2016-02-01 | 103 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-02-01 | 137 |
| Number of retired or separated participants receiving benefits | 2016-02-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2016-02-01 | 0 |
| Total of all active and inactive participants | 2016-02-01 | 137 |
| 2015: THE BRIAR TEAM, LLC WELFARE BENEFITS PLAN 2015 401k membership |
|---|
| Total participants, beginning-of-year | 2015-02-01 | 110 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-02-01 | 103 |
| Number of retired or separated participants receiving benefits | 2015-02-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2015-02-01 | 0 |
| Total of all active and inactive participants | 2015-02-01 | 103 |
| 2010: THE BRIAR TEAM, LLC WELFARE BENEFITS PLAN 2010 401k membership |
|---|
| Total participants, beginning-of-year | 2010-02-01 | 105 |
| Total number of active participants reported on line 7a of the Form 5500 | 2010-02-01 | 59 |
| Number of retired or separated participants receiving benefits | 2010-02-01 | 5 |
| Number of other retired or separated participants entitled to future benefits | 2010-02-01 | 0 |
| Total of all active and inactive participants | 2010-02-01 | 64 |
| 2009: THE BRIAR TEAM, LLC WELFARE BENEFITS PLAN 2009 401k membership |
|---|
| Total participants, beginning-of-year | 2009-02-01 | 162 |
| Total number of active participants reported on line 7a of the Form 5500 | 2009-02-01 | 151 |
| Number of retired or separated participants receiving benefits | 2009-02-01 | 7 |
| Number of other retired or separated participants entitled to future benefits | 2009-02-01 | 0 |
| Total of all active and inactive participants | 2009-02-01 | 158 |
| 2022: THE BRIAR TEAM, LLC WELFARE BENEFITS PLAN 2022 form 5500 responses |
|---|
| 2022-01-01 | Type of plan entity | Single employer plan |
| 2022-01-01 | Submission has been amended | No |
| 2022-01-01 | This submission is the final filing | No |
| 2022-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2022-01-01 | Plan is a collectively bargained plan | No |
| 2022-01-01 | Plan funding arrangement – Insurance | Yes |
| 2022-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2021: THE BRIAR TEAM, LLC WELFARE BENEFITS PLAN 2021 form 5500 responses |
|---|
| 2021-12-01 | Type of plan entity | Single employer plan |
| 2021-12-01 | Submission has been amended | No |
| 2021-12-01 | This submission is the final filing | No |
| 2021-12-01 | This return/report is a short plan year return/report (less than 12 months) | Yes |
| 2021-12-01 | Plan is a collectively bargained plan | No |
| 2021-12-01 | Plan funding arrangement – Insurance | Yes |
| 2021-12-01 | Plan benefit arrangement – Insurance | Yes |
| 2020: THE BRIAR TEAM, LLC WELFARE BENEFITS PLAN 2020 form 5500 responses |
|---|
| 2020-12-01 | Type of plan entity | Single employer plan |
| 2020-12-01 | Submission has been amended | No |
| 2020-12-01 | This submission is the final filing | No |
| 2020-12-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2020-12-01 | Plan is a collectively bargained plan | No |
| 2020-12-01 | Plan funding arrangement – Insurance | Yes |
| 2020-12-01 | Plan benefit arrangement – Insurance | Yes |
| 2019: THE BRIAR TEAM, LLC WELFARE BENEFITS PLAN 2019 form 5500 responses |
|---|
| 2019-12-01 | Type of plan entity | Single employer plan |
| 2019-12-01 | Submission has been amended | No |
| 2019-12-01 | This submission is the final filing | No |
| 2019-12-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2019-12-01 | Plan is a collectively bargained plan | No |
| 2019-12-01 | Plan funding arrangement – Insurance | Yes |
| 2019-12-01 | Plan benefit arrangement – Insurance | Yes |
| 2018: THE BRIAR TEAM, LLC WELFARE BENEFITS PLAN 2018 form 5500 responses |
|---|
| 2018-12-01 | Type of plan entity | Single employer plan |
| 2018-12-01 | Submission has been amended | No |
| 2018-12-01 | This submission is the final filing | No |
| 2018-12-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2018-12-01 | Plan is a collectively bargained plan | No |
| 2018-12-01 | Plan funding arrangement – Insurance | Yes |
| 2018-12-01 | Plan benefit arrangement – Insurance | Yes |
| 2017: THE BRIAR TEAM, LLC WELFARE BENEFITS PLAN 2017 form 5500 responses |
|---|
| 2017-12-01 | Type of plan entity | Single employer plan |
| 2017-12-01 | Submission has been amended | No |
| 2017-12-01 | This submission is the final filing | No |
| 2017-12-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2017-12-01 | Plan is a collectively bargained plan | No |
| 2017-12-01 | Plan funding arrangement – Insurance | Yes |
| 2017-12-01 | Plan benefit arrangement – Insurance | Yes |
| 2017-02-01 | Type of plan entity | Single employer plan |
| 2017-02-01 | Submission has been amended | No |
| 2017-02-01 | This submission is the final filing | No |
| 2017-02-01 | This return/report is a short plan year return/report (less than 12 months) | Yes |
| 2017-02-01 | Plan is a collectively bargained plan | No |
| 2017-02-01 | Plan funding arrangement – Insurance | Yes |
| 2017-02-01 | Plan benefit arrangement – Insurance | Yes |
| 2016: THE BRIAR TEAM, LLC WELFARE BENEFITS PLAN 2016 form 5500 responses |
|---|
| 2016-02-01 | Type of plan entity | Single employer plan |
| 2016-02-01 | Submission has been amended | No |
| 2016-02-01 | This submission is the final filing | No |
| 2016-02-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2016-02-01 | Plan is a collectively bargained plan | No |
| 2016-02-01 | Plan funding arrangement – Insurance | Yes |
| 2016-02-01 | Plan benefit arrangement – Insurance | Yes |
| 2015: THE BRIAR TEAM, LLC WELFARE BENEFITS PLAN 2015 form 5500 responses |
|---|
| 2015-02-01 | Type of plan entity | Single employer plan |
| 2015-02-01 | Submission has been amended | No |
| 2015-02-01 | This submission is the final filing | No |
| 2015-02-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2015-02-01 | Plan is a collectively bargained plan | No |
| 2015-02-01 | Plan funding arrangement – Insurance | Yes |
| 2015-02-01 | Plan benefit arrangement – Insurance | Yes |
| 2010: THE BRIAR TEAM, LLC WELFARE BENEFITS PLAN 2010 form 5500 responses |
|---|
| 2010-02-01 | Type of plan entity | Single employer plan |
| 2010-02-01 | Submission has been amended | No |
| 2010-02-01 | This submission is the final filing | No |
| 2010-02-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2010-02-01 | Plan is a collectively bargained plan | No |
| 2010-02-01 | Plan funding arrangement – Insurance | Yes |
| 2010-02-01 | Plan benefit arrangement – Insurance | Yes |
| 2009: THE BRIAR TEAM, LLC WELFARE BENEFITS PLAN 2009 form 5500 responses |
|---|
| 2009-02-01 | Type of plan entity | Single employer plan |
| 2009-02-01 | First time form 5500 has been submitted | Yes |
| 2009-02-01 | Submission has been amended | Yes |
| 2009-02-01 | This submission is the final filing | No |
| 2009-02-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2009-02-01 | Plan is a collectively bargained plan | No |
| 2009-02-01 | Plan funding arrangement – Insurance | Yes |
| 2009-02-01 | Plan benefit arrangement – Insurance | Yes |
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | OK 971467 |
| Policy instance | 5 |
| Insurance contract or identification number | OK 971467 | | Number of Individuals Covered | 177 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $456 | | 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 | 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 | VOLUNTARY AD&D | | 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 $4,560 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $456 | | Insurance broker organization code? | 3 |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 00580322 |
| Policy instance | 4 |
| Insurance contract or identification number | 00580322 | | Number of Individuals Covered | 172 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $8,647 | | Total amount of fees paid to insurance company | USD $3,045 | | 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 | 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 $86,471 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,647 | | Amount paid for insurance broker fees | 3045 | | Additional information about fees paid to insurance broker | FEES PAID | | Insurance broker organization code? | 3 |
|
| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
| Policy contract number | 00634422 |
| Policy instance | 3 |
| Insurance contract or identification number | 00634422 | | Number of Individuals Covered | 194 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $55,025 | | 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 $1,375,743 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 55025 | | Additional information about fees paid to insurance broker | BENEFIT ADVISOR FEES | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | FLI960317 |
| Policy instance | 2 |
| Insurance contract or identification number | FLI960317 | | Number of Individuals Covered | 176 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $2,209 | | 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 | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | VOLUNTARY TERM LIFE | | 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 $22,093 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,209 | | Insurance broker organization code? | 3 |
|
| AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 ) |
| Policy contract number | MQL63 |
| Policy instance | 1 |
| Insurance contract or identification number | MQL63 | | Number of Individuals Covered | 166 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $35,296 | | Total amount of fees paid to insurance company | USD $1,114 | | 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 | WORKSITE BENEFITS | | 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 $173,008 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $20,915 | | Amount paid for insurance broker fees | 813 | | Additional information about fees paid to insurance broker | FEES PAID | | Insurance broker organization code? | 3 |
|
| AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 ) |
| Policy contract number | MQL63 |
| Policy instance | 1 |
| Insurance contract or identification number | MQL63 | | Number of Individuals Covered | 168 | | Insurance policy start date | 2021-12-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $1,955 | | 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 | 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 | WORKSITE BENEFITS | | 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 $11,498 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,130 | | Insurance broker organization code? | 3 |
|
| HUMANA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 73288 ) |
| Policy contract number | 808104 |
| Policy instance | 2 |
| Insurance contract or identification number | 808104 | | Number of Individuals Covered | 116 | | Insurance policy start date | 2021-12-01 | | Insurance policy end date | 2021-12-31 | | 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? | 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 | Yes | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | BASIC AND VOLUNTARY LIFE/AD&D | | 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 $1,111 | | 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 |
|
| HUMANA MEDICAL PLAN, INC. (National Association of Insurance Commissioners NAIC id number: 95270 ) |
| Policy contract number | 808104 |
| Policy instance | 3 |
| Insurance contract or identification number | 808104 | | Number of Individuals Covered | 215 | | Insurance policy start date | 2021-12-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $6,610 | | 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 $127,842 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,610 | | Insurance broker organization code? | 3 |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 00580322 |
| Policy instance | 4 |
| Insurance contract or identification number | 00580322 | | Number of Individuals Covered | 218 | | Insurance policy start date | 2021-12-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $735 | | 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 | 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 $7,345 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $735 | | Insurance broker organization code? | 3 |
|
| AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 ) |
| Policy contract number | MQL63 |
| Policy instance | 1 |
| Insurance contract or identification number | MQL63 | | Number of Individuals Covered | 136 | | Insurance policy start date | 2020-12-01 | | Insurance policy end date | 2021-11-30 | | Total amount of commissions paid to insurance broker | USD $16,002 | | Total amount of fees paid to insurance company | USD $3,846 | | 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 | WORKSITE BENEFITS | | 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 $106,153 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $9,060 | | Amount paid for insurance broker fees | 3200 | | Additional information about fees paid to insurance broker | FEES PAID | | Insurance broker organization code? | 3 |
|
| HUMANA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 73288 ) |
| Policy contract number | 808104 |
| Policy instance | 2 |
| Insurance contract or identification number | 808104 | | Number of Individuals Covered | 61 | | Insurance policy start date | 2020-12-01 | | Insurance policy end date | 2021-11-30 | | Total amount of commissions paid to insurance broker | USD $2,347 | | 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 | Yes | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | BASIC AND VOLUNTARY LIFE/AD&D | | 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 $11,922 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,772 | | Insurance broker organization code? | 3 |
|
| COMPBENEFITS COMPANY (National Association of Insurance Commissioners NAIC id number: 52015 ) |
| Policy contract number | 808104 |
| Policy instance | 3 |
| Insurance contract or identification number | 808104 | | Number of Individuals Covered | 0 | | Insurance policy start date | 2020-12-01 | | Insurance policy end date | 2021-11-30 | | Total amount of commissions paid to insurance broker | USD $-3 | | 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 $-26 | | 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 | | Insurance broker organization code? | 3 |
|
| HUMANA MEDICAL PLAN, INC. (National Association of Insurance Commissioners NAIC id number: 95270 ) |
| Policy contract number | 808104 |
| Policy instance | 4 |
| Insurance contract or identification number | 808104 | | Number of Individuals Covered | 205 | | Insurance policy start date | 2020-12-01 | | Insurance policy end date | 2021-11-30 | | Total amount of commissions paid to insurance broker | USD $71,440 | | 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 $1,378,147 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $68,501 | | Insurance broker organization code? | 3 |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 00580322 |
| Policy instance | 5 |
| Insurance contract or identification number | 00580322 | | Number of Individuals Covered | 207 | | Insurance policy start date | 2020-12-01 | | Insurance policy end date | 2021-11-30 | | Total amount of commissions paid to insurance broker | USD $66,755 | | Total amount of fees paid to insurance company | USD $493 | | 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 | 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 $72,101 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $66,755 | | Amount paid for insurance broker fees | 493 | | Additional information about fees paid to insurance broker | FEES PAID | | Insurance broker organization code? | 3 |
|
| HUMANA MEDICAL PLAN, INC. (National Association of Insurance Commissioners NAIC id number: 95270 ) |
| Policy contract number | 808104 |
| Policy instance | 4 |
| Insurance contract or identification number | 808104 | | Number of Individuals Covered | 188 | | Insurance policy start date | 2019-12-01 | | Insurance policy end date | 2020-11-30 | | Total amount of commissions paid to insurance broker | USD $49,556 | | 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 $1,001,313 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $41,652 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | N/A | | Insurance broker organization code? | 3 |
|
| COMPBENEFITS COMPANY (National Association of Insurance Commissioners NAIC id number: 52015 ) |
| Policy contract number | 808104 |
| Policy instance | 3 |
| Insurance contract or identification number | 808104 | | Number of Individuals Covered | 65 | | Insurance policy start date | 2019-12-01 | | Insurance policy end date | 2020-11-30 | | Total amount of commissions paid to insurance broker | USD $1,300 | | 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 $12,998 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,088 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | N/A | | Insurance broker organization code? | 3 |
|
| HUMANA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 73288 ) |
| Policy contract number | 808104 |
| Policy instance | 2 |
| Insurance contract or identification number | 808104 | | Number of Individuals Covered | 266 | | Insurance policy start date | 2019-12-01 | | Insurance policy end date | 2020-11-30 | | Total amount of commissions paid to insurance broker | USD $8,497 | | 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 | Yes | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | BASIC AND VOLUNTARY LIFE/AD&D | | 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 $79,070 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,185 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | N/A | | Insurance broker organization code? | 3 |
|
| AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 ) |
| Policy contract number | MQL63 |
| Policy instance | 1 |
| Insurance contract or identification number | MQL63 | | Number of Individuals Covered | 114 | | Insurance policy start date | 2019-12-01 | | Insurance policy end date | 2020-11-30 | | Total amount of commissions paid to insurance broker | USD $44,106 | | Total amount of fees paid to insurance company | USD $2,568 | | 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 | WORKSITE BENEFITS | | 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 $119,587 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $14,777 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | N/A | | Insurance broker organization code? | 3 |
|
| HUMANA MEDICAL PLAN, INC. (National Association of Insurance Commissioners NAIC id number: 95270 ) |
| Policy contract number | 808104 |
| Policy instance | 4 |
| Insurance contract or identification number | 808104 | | Number of Individuals Covered | 193 | | Insurance policy start date | 2018-12-01 | | Insurance policy end date | 2019-11-30 | | Total amount of commissions paid to insurance broker | USD $44,406 | | 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 $888,125 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $33,406 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | N/A | | Insurance broker organization code? | 3 |
|
| COMPBENEFITS COMPANY (National Association of Insurance Commissioners NAIC id number: 52015 ) |
| Policy contract number | 808104 |
| Policy instance | 3 |
| Insurance contract or identification number | 808104 | | Number of Individuals Covered | 34 | | Insurance policy start date | 2018-12-01 | | Insurance policy end date | 2019-11-30 | | Total amount of commissions paid to insurance broker | USD $426 | | Total amount of fees paid to insurance company | USD $75 | | 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 $4,258 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $317 | | Amount paid for insurance broker fees | 75 | | Additional information about fees paid to insurance broker | BONUS | | Insurance broker organization code? | 3 |
|
| TRANSAMERICA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 86231 ) |
| Policy contract number | ER00021171 |
| Policy instance | 1 |
| Insurance contract or identification number | ER00021171 | | Number of Individuals Covered | 130 | | Insurance policy start date | 2018-12-01 | | Insurance policy end date | 2019-11-30 | | Total amount of commissions paid to insurance broker | USD $20,740 | | 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 | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENT, CANCER, HOSPITAL | | 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 $91,688 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $12,714 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | N/A | | Insurance broker organization code? | 3 |
|
| HUMANA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 73288 ) |
| Policy contract number | 808104 |
| Policy instance | 2 |
| Insurance contract or identification number | 808104 | | Number of Individuals Covered | 133 | | Insurance policy start date | 2018-12-01 | | Insurance policy end date | 2019-11-30 | | Total amount of commissions paid to insurance broker | USD $6,230 | | Total amount of fees paid to insurance company | USD $925 | | 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 | 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 $62,303 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,676 | | Amount paid for insurance broker fees | 925 | | Additional information about fees paid to insurance broker | BONUS | | Insurance broker organization code? | 3 |
|
| TRANSAMERICA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 86231 ) |
| Policy contract number | ER00021171 |
| Policy instance | 3 |
| Insurance contract or identification number | ER00021171 | | Number of Individuals Covered | 563 | | Insurance policy start date | 2017-12-01 | | Insurance policy end date | 2018-11-30 | | Total amount of commissions paid to insurance broker | USD $16,261 | | 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 | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENT, CANCER, HOSPITAL | | 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 $82,432 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| BLUE CROSS BLUE SHIELD OF FLORIDA (National Association of Insurance Commissioners NAIC id number: 95089 ) |
| Policy contract number | 68621 |
| Policy instance | 2 |
| Insurance contract or identification number | 68621 | | Number of Individuals Covered | 163 | | Insurance policy start date | 2017-12-01 | | Insurance policy end date | 2018-11-30 | | Total amount of commissions paid to insurance broker | USD $36,264 | | 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 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 445770 |
| Policy instance | 1 |
| Insurance contract or identification number | 445770 | | Number of Individuals Covered | 137 | | Insurance policy start date | 2017-12-01 | | Insurance policy end date | 2018-11-30 | | Total amount of commissions paid to insurance broker | USD $6,854 | | Total amount of fees paid to insurance company | USD $2,862 | | 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 | Yes | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | OPTIONAL LIFE | | 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 $82,458 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 00445770 |
| Policy instance | 1 |
| Insurance contract or identification number | 00445770 | | Number of Individuals Covered | 127 | | Insurance policy start date | 2016-12-01 | | Insurance policy end date | 2017-11-30 | | Total amount of commissions paid to insurance broker | USD $4,608 | | Total amount of fees paid to insurance company | USD $956 | | 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 | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | 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 $57,846 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,542 | | Amount paid for insurance broker fees | 956 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker organization code? | 3 | | Insurance broker name | HARRISON-DAVIS INC. |
|
| HUMANA MEDICAL PLAN, INC. (National Association of Insurance Commissioners NAIC id number: 95270 ) |
| Policy contract number | 673257 |
| Policy instance | 2 |
| Insurance contract or identification number | 673257 | | Number of Individuals Covered | 171 | | Insurance policy start date | 2016-12-01 | | Insurance policy end date | 2017-11-30 | | Total amount of commissions paid to insurance broker | USD $46,121 | | 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 $768,685 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $46,121 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | N/A | | Insurance broker organization code? | 3 | | Insurance broker name | CHARLES F. BOSTROM |
|
| TRANSAMERICA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 86231 ) |
| Policy contract number | ER00021171 |
| Policy instance | 3 |
| Insurance contract or identification number | ER00021171 | | Number of Individuals Covered | 478 | | Insurance policy start date | 2016-12-01 | | Insurance policy end date | 2017-11-30 | | Total amount of commissions paid to insurance broker | USD $989 | | 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 | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENT, CANCER, HOSPITAL | | 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 $95,707 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $287 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | N/A | | Insurance broker organization code? | 3 | | Insurance broker name | JEFFERY T. MEYER |
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| HUMANA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 73288 ) |
| Policy contract number | 673257 |
| Policy instance | 4 |
| Insurance contract or identification number | 673257 | | Number of Individuals Covered | 44 | | Insurance policy start date | 2016-12-01 | | Insurance policy end date | 2017-11-30 | | Total amount of commissions paid to insurance broker | USD $564 | | 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 $5,640 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $564 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | N/A | | Insurance broker organization code? | 3 | | Insurance broker name | CHARLES F. BOSTROM |
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| HUMANA MEDICAL PLAN, INC. (National Association of Insurance Commissioners NAIC id number: 95270 ) |
| Policy contract number | 673257 |
| Policy instance | 2 |
| Insurance contract or identification number | 673257 | | Number of Individuals Covered | 126 | | Insurance policy start date | 2015-12-01 | | Insurance policy end date | 2016-11-30 | | Total amount of commissions paid to insurance broker | USD $38,185 | | 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 $636,420 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $38,185 | | Insurance broker organization code? | 3 | | Insurance broker name | CHARLES BOSTROM |
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| TRANSAMERICA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 86231 ) |
| Policy contract number | ER00021171 |
| Policy instance | 3 |
| Insurance contract or identification number | ER00021171 | | Number of Individuals Covered | 115 | | Insurance policy start date | 2015-12-01 | | Insurance policy end date | 2016-11-30 | | Total amount of commissions paid to insurance broker | USD $614 | | 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 | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENT, CANCER, HOSP | | 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 $3,760 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $182 | | Insurance broker organization code? | 3 | | Insurance broker name | ENROLLMENT SERVICES INC |
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| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 00445770 |
| Policy instance | 1 |
| Insurance contract or identification number | 00445770 | | Number of Individuals Covered | 89 | | Insurance policy start date | 2015-12-01 | | Insurance policy end date | 2016-11-30 | | Total amount of commissions paid to insurance broker | USD $3,320 | | Total amount of fees paid to insurance company | USD $476 | | 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 | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | 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 $45,150 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,303 | | Amount paid for insurance broker fees | 476 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | HARRISON-DAVIS INC. |
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| HUMANA MEDICAL PLAN, INC. (National Association of Insurance Commissioners NAIC id number: 95270 ) |
| Policy contract number | 673257 |
| Policy instance | 2 |
| Insurance contract or identification number | 673257 | | Number of Individuals Covered | 119 | | Insurance policy start date | 2014-12-01 | | Insurance policy end date | 2015-11-30 | | Total amount of commissions paid to insurance broker | USD $33,803 | | 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 $550,551 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $33,803 | | Insurance broker organization code? | 3 | | Insurance broker name | CHARLES BOSTROM |
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| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 00445770 |
| Policy instance | 1 |
| Insurance contract or identification number | 00445770 | | Number of Individuals Covered | 103 | | Insurance policy start date | 2015-02-01 | | Insurance policy end date | 2016-01-31 | | Total amount of commissions paid to insurance broker | USD $626 | | 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 | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | 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 $17,455 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $609 | | Insurance broker organization code? | 3 | | Insurance broker name | HARRISON-DAVIS INC. |
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| TRANSAMERICA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 86231 ) |
| Policy contract number | ER00021171 |
| Policy instance | 3 |
| Insurance contract or identification number | ER00021171 | | Number of Individuals Covered | 190 | | Insurance policy start date | 2015-02-01 | | Insurance policy end date | 2016-01-31 | | Total amount of commissions paid to insurance broker | USD $9,406 | | 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 | 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 $40,647 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $9,406 | | Insurance broker organization code? | 3 | | Insurance broker name | SEE ATTACHED |
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| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 00445770 |
| Policy instance | 1 |
| Insurance contract or identification number | 00445770 | | Number of Individuals Covered | 72 | | Insurance policy start date | 2010-02-01 | | Insurance policy end date | 2011-01-31 | | Total amount of commissions paid to insurance broker | USD $1,259 | | 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 | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | 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 $44,155 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,259 | | Insurance broker organization code? | 3 | | Insurance broker name | THOMPSON BOSTROM & ASSOC |
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| AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 ) |
| Policy contract number | BG901 |
| Policy instance | 2 |
| Insurance contract or identification number | BG901 | | Number of Individuals Covered | 71 | | Insurance policy start date | 2010-02-01 | | Insurance policy end date | 2011-01-31 | | Total amount of commissions paid to insurance broker | USD $16,309 | | 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 | 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 $42,406 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,658 | | Insurance broker organization code? | 3 | | Insurance broker name | BOSTROM GRAESSLE & BOSTROM |
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| BLUE CROSS BLUE SHIELD OF FLORIDA (National Association of Insurance Commissioners NAIC id number: 98167 ) |
| Policy contract number | 68621 |
| Policy instance | 3 |
| Insurance contract or identification number | 68621 | | Number of Individuals Covered | 75 | | Insurance policy start date | 2010-02-01 | | Insurance policy end date | 2011-01-31 | | 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 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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