MESA FULLY FORMED, LLC has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan MESA FULLY FORMED HEALTH & WELFARE BENEFIT PLAN
401k plan membership statisitcs for MESA FULLY FORMED HEALTH & WELFARE BENEFIT PLAN
| Measure | Date | Value |
|---|
| 2022: MESA FULLY FORMED HEALTH & WELFARE BENEFIT PLAN 2022 401k membership |
|---|
| Total participants, beginning-of-year | 2022-03-01 | 309 |
| Total number of active participants reported on line 7a of the Form 5500 | 2022-03-01 | 306 |
| Number of retired or separated participants receiving benefits | 2022-03-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2022-03-01 | 0 |
| Total of all active and inactive participants | 2022-03-01 | 306 |
| Number of employers contributing to the scheme | 2022-03-01 | 0 |
| 2021: MESA FULLY FORMED HEALTH & WELFARE BENEFIT PLAN 2021 401k membership |
|---|
| Total participants, beginning-of-year | 2021-03-01 | 302 |
| Total number of active participants reported on line 7a of the Form 5500 | 2021-03-01 | 309 |
| Number of retired or separated participants receiving benefits | 2021-03-01 | 1 |
| Number of other retired or separated participants entitled to future benefits | 2021-03-01 | 0 |
| Total of all active and inactive participants | 2021-03-01 | 310 |
| Number of employers contributing to the scheme | 2021-03-01 | 0 |
| 2020: MESA FULLY FORMED HEALTH & WELFARE BENEFIT PLAN 2020 401k membership |
|---|
| Total participants, beginning-of-year | 2020-03-01 | 302 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-03-01 | 305 |
| Number of retired or separated participants receiving benefits | 2020-03-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2020-03-01 | 0 |
| Total of all active and inactive participants | 2020-03-01 | 305 |
| Number of employers contributing to the scheme | 2020-03-01 | 0 |
| 2019: MESA FULLY FORMED HEALTH & WELFARE BENEFIT PLAN 2019 401k membership |
|---|
| Total participants, beginning-of-year | 2019-03-01 | 262 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-03-01 | 309 |
| Number of retired or separated participants receiving benefits | 2019-03-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2019-03-01 | 0 |
| Total of all active and inactive participants | 2019-03-01 | 309 |
| 2018: MESA FULLY FORMED HEALTH & WELFARE BENEFIT PLAN 2018 401k membership |
|---|
| Total participants, beginning-of-year | 2018-03-01 | 262 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-03-01 | 295 |
| Number of retired or separated participants receiving benefits | 2018-03-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2018-03-01 | 0 |
| Total of all active and inactive participants | 2018-03-01 | 295 |
| 2017: MESA FULLY FORMED HEALTH & WELFARE BENEFIT PLAN 2017 401k membership |
|---|
| Total participants, beginning-of-year | 2017-03-01 | 259 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-03-01 | 263 |
| Number of retired or separated participants receiving benefits | 2017-03-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2017-03-01 | 0 |
| Total of all active and inactive participants | 2017-03-01 | 263 |
| 2016: MESA FULLY FORMED HEALTH & WELFARE BENEFIT PLAN 2016 401k membership |
|---|
| Total participants, beginning-of-year | 2016-03-01 | 235 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-03-01 | 259 |
| Number of retired or separated participants receiving benefits | 2016-03-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2016-03-01 | 0 |
| Total of all active and inactive participants | 2016-03-01 | 259 |
| 2015: MESA FULLY FORMED HEALTH & WELFARE BENEFIT PLAN 2015 401k membership |
|---|
| Total participants, beginning-of-year | 2015-03-01 | 189 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-03-01 | 235 |
| Number of retired or separated participants receiving benefits | 2015-03-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2015-03-01 | 0 |
| Total of all active and inactive participants | 2015-03-01 | 235 |
| 2014: MESA FULLY FORMED HEALTH & WELFARE BENEFIT PLAN 2014 401k membership |
|---|
| Total participants, beginning-of-year | 2014-03-01 | 172 |
| Total number of active participants reported on line 7a of the Form 5500 | 2014-03-01 | 189 |
| Number of retired or separated participants receiving benefits | 2014-03-01 | 1 |
| Number of other retired or separated participants entitled to future benefits | 2014-03-01 | 0 |
| Total of all active and inactive participants | 2014-03-01 | 190 |
| 2013: MESA FULLY FORMED HEALTH & WELFARE BENEFIT PLAN 2013 401k membership |
|---|
| Total participants, beginning-of-year | 2013-03-01 | 136 |
| Total number of active participants reported on line 7a of the Form 5500 | 2013-03-01 | 174 |
| Number of retired or separated participants receiving benefits | 2013-03-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2013-03-01 | 0 |
| Total of all active and inactive participants | 2013-03-01 | 174 |
| 2012: MESA FULLY FORMED HEALTH & WELFARE BENEFIT PLAN 2012 401k membership |
|---|
| Total participants, beginning-of-year | 2012-03-01 | 134 |
| Total number of active participants reported on line 7a of the Form 5500 | 2012-03-01 | 141 |
| Number of retired or separated participants receiving benefits | 2012-03-01 | 1 |
| Number of other retired or separated participants entitled to future benefits | 2012-03-01 | 0 |
| Total of all active and inactive participants | 2012-03-01 | 142 |
| 2011: MESA FULLY FORMED HEALTH & WELFARE BENEFIT PLAN 2011 401k membership |
|---|
| Total participants, beginning-of-year | 2011-03-01 | 199 |
| Total number of active participants reported on line 7a of the Form 5500 | 2011-03-01 | 133 |
| Number of retired or separated participants receiving benefits | 2011-03-01 | 1 |
| Number of other retired or separated participants entitled to future benefits | 2011-03-01 | 0 |
| Total of all active and inactive participants | 2011-03-01 | 134 |
| 2009: MESA FULLY FORMED HEALTH & WELFARE BENEFIT PLAN 2009 401k membership |
|---|
| Total participants, beginning-of-year | 2009-03-01 | 239 |
| Total number of active participants reported on line 7a of the Form 5500 | 2009-03-01 | 170 |
| Number of retired or separated participants receiving benefits | 2009-03-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2009-03-01 | 0 |
| Total of all active and inactive participants | 2009-03-01 | 170 |
| Total participants | 2009-03-01 | 0 |
| 2022: MESA FULLY FORMED HEALTH & WELFARE BENEFIT PLAN 2022 form 5500 responses |
|---|
| 2022-03-01 | Type of plan entity | Single employer plan |
| 2022-03-01 | Plan funding arrangement – Insurance | Yes |
| 2022-03-01 | Plan benefit arrangement – Insurance | Yes |
| 2021: MESA FULLY FORMED HEALTH & WELFARE BENEFIT PLAN 2021 form 5500 responses |
|---|
| 2021-03-01 | Type of plan entity | Single employer plan |
| 2021-03-01 | Plan funding arrangement – Insurance | Yes |
| 2021-03-01 | Plan benefit arrangement – Insurance | Yes |
| 2020: MESA FULLY FORMED HEALTH & WELFARE BENEFIT PLAN 2020 form 5500 responses |
|---|
| 2020-03-01 | Type of plan entity | Single employer plan |
| 2020-03-01 | Plan funding arrangement – Insurance | Yes |
| 2020-03-01 | Plan benefit arrangement – Insurance | Yes |
| 2019: MESA FULLY FORMED HEALTH & WELFARE BENEFIT PLAN 2019 form 5500 responses |
|---|
| 2019-03-01 | Type of plan entity | Single employer plan |
| 2019-03-01 | Submission has been amended | No |
| 2019-03-01 | This submission is the final filing | No |
| 2019-03-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2019-03-01 | Plan is a collectively bargained plan | No |
| 2019-03-01 | Plan funding arrangement – Insurance | Yes |
| 2019-03-01 | Plan benefit arrangement – Insurance | Yes |
| 2018: MESA FULLY FORMED HEALTH & WELFARE BENEFIT PLAN 2018 form 5500 responses |
|---|
| 2018-03-01 | Type of plan entity | Single employer plan |
| 2018-03-01 | Submission has been amended | No |
| 2018-03-01 | This submission is the final filing | No |
| 2018-03-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2018-03-01 | Plan is a collectively bargained plan | No |
| 2018-03-01 | Plan funding arrangement – Insurance | Yes |
| 2018-03-01 | Plan benefit arrangement – Insurance | Yes |
| 2017: MESA FULLY FORMED HEALTH & WELFARE BENEFIT PLAN 2017 form 5500 responses |
|---|
| 2017-03-01 | Type of plan entity | Single employer plan |
| 2017-03-01 | Submission has been amended | No |
| 2017-03-01 | This submission is the final filing | No |
| 2017-03-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2017-03-01 | Plan is a collectively bargained plan | No |
| 2017-03-01 | Plan funding arrangement – Insurance | Yes |
| 2017-03-01 | Plan benefit arrangement – Insurance | Yes |
| 2016: MESA FULLY FORMED HEALTH & WELFARE BENEFIT PLAN 2016 form 5500 responses |
|---|
| 2016-03-01 | Type of plan entity | Single employer plan |
| 2016-03-01 | Submission has been amended | No |
| 2016-03-01 | This submission is the final filing | No |
| 2016-03-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2016-03-01 | Plan is a collectively bargained plan | No |
| 2016-03-01 | Plan funding arrangement – Insurance | Yes |
| 2016-03-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2016-03-01 | Plan benefit arrangement – Insurance | Yes |
| 2016-03-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2015: MESA FULLY FORMED HEALTH & WELFARE BENEFIT PLAN 2015 form 5500 responses |
|---|
| 2015-03-01 | Type of plan entity | Single employer plan |
| 2015-03-01 | Submission has been amended | No |
| 2015-03-01 | This submission is the final filing | No |
| 2015-03-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2015-03-01 | Plan is a collectively bargained plan | No |
| 2015-03-01 | Plan funding arrangement – Insurance | Yes |
| 2015-03-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2015-03-01 | Plan benefit arrangement – Insurance | Yes |
| 2015-03-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2014: MESA FULLY FORMED HEALTH & WELFARE BENEFIT PLAN 2014 form 5500 responses |
|---|
| 2014-03-01 | Type of plan entity | Single employer plan |
| 2014-03-01 | Submission has been amended | No |
| 2014-03-01 | This submission is the final filing | No |
| 2014-03-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2014-03-01 | Plan is a collectively bargained plan | No |
| 2014-03-01 | Plan funding arrangement – Insurance | Yes |
| 2014-03-01 | Plan benefit arrangement – Insurance | Yes |
| 2013: MESA FULLY FORMED HEALTH & WELFARE BENEFIT PLAN 2013 form 5500 responses |
|---|
| 2013-03-01 | Type of plan entity | Single employer plan |
| 2013-03-01 | Submission has been amended | No |
| 2013-03-01 | This submission is the final filing | No |
| 2013-03-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2013-03-01 | Plan is a collectively bargained plan | No |
| 2013-03-01 | Plan funding arrangement – Insurance | Yes |
| 2013-03-01 | Plan benefit arrangement – Insurance | Yes |
| 2012: MESA FULLY FORMED HEALTH & WELFARE BENEFIT PLAN 2012 form 5500 responses |
|---|
| 2012-03-01 | Type of plan entity | Single employer plan |
| 2012-03-01 | Submission has been amended | No |
| 2012-03-01 | This submission is the final filing | No |
| 2012-03-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2012-03-01 | Plan is a collectively bargained plan | No |
| 2012-03-01 | Plan funding arrangement – Insurance | Yes |
| 2012-03-01 | Plan benefit arrangement – Insurance | Yes |
| 2011: MESA FULLY FORMED HEALTH & WELFARE BENEFIT PLAN 2011 form 5500 responses |
|---|
| 2011-03-01 | Type of plan entity | Single employer plan |
| 2011-03-01 | Submission has been amended | No |
| 2011-03-01 | This submission is the final filing | No |
| 2011-03-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2011-03-01 | Plan is a collectively bargained plan | No |
| 2011-03-01 | Plan funding arrangement – Insurance | Yes |
| 2011-03-01 | Plan benefit arrangement – Insurance | Yes |
| 2009: MESA FULLY FORMED HEALTH & WELFARE BENEFIT PLAN 2009 form 5500 responses |
|---|
| 2009-03-01 | Type of plan entity | Single employer plan |
| 2009-03-01 | Submission has been amended | No |
| 2009-03-01 | This submission is the final filing | No |
| 2009-03-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2009-03-01 | Plan is a collectively bargained plan | No |
| 2009-03-01 | Plan funding arrangement – Insurance | Yes |
| 2009-03-01 | Plan benefit arrangement – Insurance | Yes |
| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | 10139926 |
| Policy instance | 2 |
| Insurance contract or identification number | 10139926 | | Number of Individuals Covered | 306 | | Insurance policy start date | 2022-03-01 | | Insurance policy end date | 2023-02-28 | | Total amount of commissions paid to insurance broker | USD $4,512 | | Total amount of fees paid to insurance company | USD $1,044 | | 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 | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $30,079 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,512 | | Amount paid for insurance broker fees | 1044 | | Additional information about fees paid to insurance broker | BROKER BONUS | | Insurance broker organization code? | 3 |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 910871 |
| Policy instance | 1 |
| Insurance contract or identification number | 910871 | | Number of Individuals Covered | 255 | | Insurance policy start date | 2022-03-01 | | Insurance policy end date | 2023-02-28 | | Total amount of commissions paid to insurance broker | USD $5,613 | | Total amount of fees paid to insurance company | USD $49,912 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $892,414 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,613 | | Amount paid for insurance broker fees | 49912 | | Additional information about fees paid to insurance broker | SERVICE FEE AGREEMENT, BONUS | | Insurance broker organization code? | 2 |
|
| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | 10139926 |
| Policy instance | 2 |
| Insurance contract or identification number | 10139926 | | Number of Individuals Covered | 307 | | Insurance policy start date | 2021-03-01 | | Insurance policy end date | 2022-02-28 | | Total amount of commissions paid to insurance broker | USD $5,006 | | Total amount of fees paid to insurance company | USD $974 | | 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 | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $33,370 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,006 | | Amount paid for insurance broker fees | 974 | | Additional information about fees paid to insurance broker | BROKER BONUS | | Insurance broker organization code? | 3 |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 910871 |
| Policy instance | 1 |
| Insurance contract or identification number | 910871 | | Number of Individuals Covered | 290 | | Insurance policy start date | 2021-03-01 | | Insurance policy end date | 2022-02-28 | | Total amount of commissions paid to insurance broker | USD $6,141 | | Total amount of fees paid to insurance company | USD $61,873 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,002,463 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,141 | | Amount paid for insurance broker fees | 61873 | | Additional information about fees paid to insurance broker | SERVICE FEE AGREEMENT, BONUS | | Insurance broker organization code? | 3 |
|
| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | 10139926 |
| Policy instance | 2 |
| Insurance contract or identification number | 10139926 | | Number of Individuals Covered | 301 | | Insurance policy start date | 2020-03-01 | | Insurance policy end date | 2021-02-28 | | Total amount of commissions paid to insurance broker | USD $4,531 | | Total amount of fees paid to insurance company | USD $946 | | 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 | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $30,206 | | 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 | 946 | | Additional information about fees paid to insurance broker | BROKER BONUS | | Insurance broker organization code? | 3 |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 910871 |
| Policy instance | 1 |
| Insurance contract or identification number | 910871 | | Number of Individuals Covered | 578 | | Insurance policy start date | 2020-03-01 | | Insurance policy end date | 2021-02-28 | | Total amount of commissions paid to insurance broker | USD $6,093 | | Total amount of fees paid to insurance company | USD $70,401 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,138,593 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,093 | | Amount paid for insurance broker fees | 70401 | | Additional information about fees paid to insurance broker | SERVICE FEE AGREEMENT BONUS | | Insurance broker organization code? | 3 |
|
| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | 400001000 12993 |
| Policy instance | 1 |
| Insurance contract or identification number | 400001000 12993 | | Number of Individuals Covered | 39 | | Insurance policy start date | 2019-03-01 | | Insurance policy end date | 2020-02-29 | | Total amount of commissions paid to insurance broker | USD $3,130 | | Total amount of fees paid to insurance company | USD $561 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | VOLUNTARY ACCIDENTAL DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $20,866 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,130 | | Amount paid for insurance broker fees | 561 | | Additional information about fees paid to insurance broker | BROKER BONUS | | Insurance broker organization code? | 3 |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 910871 |
| Policy instance | 2 |
| Insurance contract or identification number | 910871 | | Number of Individuals Covered | 293 | | Insurance policy start date | 2019-03-01 | | Insurance policy end date | 2020-02-29 | | Total amount of commissions paid to insurance broker | USD $6,249 | | Total amount of fees paid to insurance company | USD $57,786 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $856,689 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,249 | | Amount paid for insurance broker fees | 57786 | | Additional information about fees paid to insurance broker | SERVICE FEE AGREEMENT | | Insurance broker organization code? | 3 |
|
| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | 000010139926 |
| Policy instance | 3 |
| Insurance contract or identification number | 000010139926 | | Number of Individuals Covered | 304 | | Insurance policy start date | 2019-03-01 | | Insurance policy end date | 2020-02-29 | | Total amount of commissions paid to insurance broker | USD $1,149 | | Total amount of fees paid to insurance company | USD $214 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $7,661 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,149 | | Amount paid for insurance broker fees | 214 | | Additional information about fees paid to insurance broker | BROKER BONUS | | Insurance broker organization code? | 3 |
|
| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | 000010139926 |
| Policy instance | 4 |
| Insurance contract or identification number | 000010139926 | | Number of Individuals Covered | 304 | | Insurance policy start date | 2018-03-01 | | Insurance policy end date | 2019-02-28 | | Total amount of commissions paid to insurance broker | USD $1,082 | | Total amount of fees paid to insurance company | USD $272 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $7,212 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,082 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 272 | | Additional information about fees paid to insurance broker | BROKER BONUS |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 910871 |
| Policy instance | 3 |
| Insurance contract or identification number | 910871 | | Number of Individuals Covered | 250 | | Insurance policy start date | 2018-03-01 | | Insurance policy end date | 2019-02-28 | | Total amount of commissions paid to insurance broker | USD $1,158 | | Total amount of fees paid to insurance company | USD $53,587 | | Health Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $851,496 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,158 | | Amount paid for insurance broker fees | 53587 | | Additional information about fees paid to insurance broker | SERVICE FEE AGREEMENT | | Insurance broker organization code? | 3 |
|
| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | 400001000 12993 |
| Policy instance | 2 |
| Insurance contract or identification number | 400001000 12993 | | Number of Individuals Covered | 35 | | Insurance policy start date | 2018-03-01 | | Insurance policy end date | 2019-02-28 | | Total amount of commissions paid to insurance broker | USD $2,820 | | Total amount of fees paid to insurance company | USD $714 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | VOLUNTARY ACCIDENTAL DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $18,799 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,820 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 714 | | Additional information about fees paid to insurance broker | BROKER BONUS |
|
| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | 00040D021618 |
| Policy instance | 1 |
| Insurance contract or identification number | 00040D021618 | | Number of Individuals Covered | 123 | | Insurance policy start date | 2018-03-01 | | Insurance policy end date | 2019-02-28 | | Total amount of commissions paid to insurance broker | USD $3,926 | | Total amount of fees paid to insurance company | USD $716 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $39,257 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,926 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 716 | | Additional information about fees paid to insurance broker | BROKER BONUS |
|
| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | 000010139926 |
| Policy instance | 4 |
| Insurance contract or identification number | 000010139926 | | Number of Individuals Covered | 263 | | Insurance policy start date | 2017-03-01 | | Insurance policy end date | 2018-02-28 | | Total amount of commissions paid to insurance broker | USD $1,030 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $6,868 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,030 | | Insurance broker organization code? | 3 | | Insurance broker name | MJ INSURANCE, INC. |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 910871 |
| Policy instance | 3 |
| Insurance contract or identification number | 910871 | | Number of Individuals Covered | 229 | | Insurance policy start date | 2017-03-01 | | Insurance policy end date | 2018-02-28 | | Total amount of commissions paid to insurance broker | USD $943 | | Total amount of fees paid to insurance company | USD $48,883 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $775,622 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $943 | | Amount paid for insurance broker fees | 48883 | | Additional information about fees paid to insurance broker | SERVICE FEE AGREEMENT | | Insurance broker organization code? | 3 | | Insurance broker name | MJ INSURANCE INC. |
|
| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | 400001000 12993 |
| Policy instance | 2 |
| Insurance contract or identification number | 400001000 12993 | | Number of Individuals Covered | 35 | | Insurance policy start date | 2017-03-01 | | Insurance policy end date | 2018-02-28 | | Total amount of commissions paid to insurance broker | USD $2,654 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | VOLUNTARY ACCIDENTAL DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $17,694 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,654 | | Insurance broker organization code? | 3 | | Insurance broker name | MJ INSURANCE INC. |
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| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | 00040D021618 |
| Policy instance | 1 |
| Insurance contract or identification number | 00040D021618 | | Number of Individuals Covered | 109 | | Insurance policy start date | 2017-03-01 | | Insurance policy end date | 2018-02-28 | | Total amount of commissions paid to insurance broker | USD $3,599 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $35,987 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,599 | | Insurance broker organization code? | 3 | | Insurance broker name | MJ INSURANCE INC. |
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| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | 000010139926 |
| Policy instance | 3 |
| Insurance contract or identification number | 000010139926 | | Number of Individuals Covered | 232 | | Insurance policy start date | 2015-03-01 | | Insurance policy end date | 2016-02-29 | | Total amount of commissions paid to insurance broker | USD $791 | | Total amount of fees paid to insurance company | USD $113 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $5,274 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $791 | | Amount paid for insurance broker fees | 113 | | Additional information about fees paid to insurance broker | BROKER BONUS | | Insurance broker organization code? | 3 | | Insurance broker name | MJ INSURANCE, INC. |
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| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | 400001000 12993 |
| Policy instance | 2 |
| Insurance contract or identification number | 400001000 12993 | | Number of Individuals Covered | 35 | | Insurance policy start date | 2015-03-01 | | Insurance policy end date | 2016-02-29 | | Total amount of commissions paid to insurance broker | USD $2,286 | | Total amount of fees paid to insurance company | USD $509 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | VOLUNTARY ACCIDENTAL DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $15,240 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,286 | | Amount paid for insurance broker fees | 509 | | Additional information about fees paid to insurance broker | BROKER BONUS | | Insurance broker organization code? | 3 | | Insurance broker name | MJ INSURANCE INC. |
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| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | 00040D021618 |
| Policy instance | 1 |
| Insurance contract or identification number | 00040D021618 | | Number of Individuals Covered | 98 | | Insurance policy start date | 2015-03-01 | | Insurance policy end date | 2016-02-29 | | Total amount of commissions paid to insurance broker | USD $2,949 | | Total amount of fees paid to insurance company | USD $417 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $29,490 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,949 | | Amount paid for insurance broker fees | 417 | | Additional information about fees paid to insurance broker | BROKER BONUS | | Insurance broker organization code? | 3 | | Insurance broker name | MJ INSURANCE INC. |
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| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | 000010139926 |
| Policy instance | 3 |
| Insurance contract or identification number | 000010139926 | | Number of Individuals Covered | 186 | | Insurance policy start date | 2014-03-01 | | Insurance policy end date | 2015-02-28 | | Total amount of commissions paid to insurance broker | USD $516 | | Total amount of fees paid to insurance company | USD $38 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $3,441 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $516 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 38 | | Additional information about fees paid to insurance broker | BROKER BONUS | | Insurance broker name | MJ INSURANCE, INC. |
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| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | 00040D021618 |
| Policy instance | 1 |
| Insurance contract or identification number | 00040D021618 | | Number of Individuals Covered | 82 | | Insurance policy start date | 2014-03-01 | | Insurance policy end date | 2015-02-28 | | Total amount of commissions paid to insurance broker | USD $2,549 | | Total amount of fees paid to insurance company | USD $78 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $25,490 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,549 | | Amount paid for insurance broker fees | 78 | | Additional information about fees paid to insurance broker | BROKER BONUS | | Insurance broker organization code? | 3 | | Insurance broker name | MJ INSURANCE INC. |
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| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | 400001000 12993 |
| Policy instance | 2 |
| Insurance contract or identification number | 400001000 12993 | | Number of Individuals Covered | 33 | | Insurance policy start date | 2014-03-01 | | Insurance policy end date | 2015-02-28 | | Total amount of commissions paid to insurance broker | USD $2,289 | | Total amount of fees paid to insurance company | USD $201 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | VOLUNTARY ACCIDENTAL DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $15,258 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,289 | | Amount paid for insurance broker fees | 201 | | Additional information about fees paid to insurance broker | BROKER BONUS | | Insurance broker organization code? | 3 | | Insurance broker name | MJ INSURANCE INC. |
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| HEALTH NET OF AZ (National Association of Insurance Commissioners NAIC id number: 66141 ) |
| Policy contract number | Z13555 |
| Policy instance | 4 |
| Insurance contract or identification number | Z13555 | | Number of Individuals Covered | 113 | | Insurance policy start date | 2014-03-01 | | Insurance policy end date | 2015-02-28 | | Total amount of commissions paid to insurance broker | USD $30,183 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $603,661 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $30,183 | | Insurance broker organization code? | 3 | | Insurance broker name | MJ INSURANCE, INC. |
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| HEALTH NET OF AZ (National Association of Insurance Commissioners NAIC id number: 66141 ) |
| Policy contract number | Z13555 |
| Policy instance | 2 |
| Insurance contract or identification number | Z13555 | | Number of Individuals Covered | 106 | | Insurance policy start date | 2013-03-01 | | Insurance policy end date | 2014-02-28 | | Total amount of commissions paid to insurance broker | USD $23,182 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $509,729 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $23,182 | | Insurance broker organization code? | 3 | | Insurance broker name | MJ INSURANCE, INC. |
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| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | 000010139926 |
| Policy instance | 1 |
| Insurance contract or identification number | 000010139926 | | Number of Individuals Covered | 174 | | Insurance policy start date | 2013-03-01 | | Insurance policy end date | 2014-02-28 | | Total amount of commissions paid to insurance broker | USD $405 | | Total amount of fees paid to insurance company | USD $40 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $2,702 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $405 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 40 | | Additional information about fees paid to insurance broker | BROKER BONUS | | Insurance broker name | MJ INSURANCE, INC. |
|
| HEALTH NET OF AZ (National Association of Insurance Commissioners NAIC id number: 66141 ) |
| Policy contract number | Z13555 |
| Policy instance | 4 |
| Insurance contract or identification number | Z13555 | | Number of Individuals Covered | 86 | | Insurance policy start date | 2012-03-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $17,107 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $380,399 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $17,107 | | Insurance broker organization code? | 3 | | Insurance broker name | MJ INSURANCE, INC. |
|
| HEALTH NET OF AZ (National Association of Insurance Commissioners NAIC id number: 66141 ) |
| Policy contract number | Z13555 |
| Policy instance | 3 |
| Insurance contract or identification number | Z13555 | | Number of Individuals Covered | 85 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-02-28 | | Total amount of commissions paid to insurance broker | USD $3,645 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $73,597 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,645 | | Insurance broker organization code? | 3 | | Insurance broker name | MJ INSURANCE, INC. |
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| HEALTH NET OF AZ (National Association of Insurance Commissioners NAIC id number: 66141 ) |
| Policy contract number | Z13555 |
| Policy instance | 2 |
| Insurance contract or identification number | Z13555 | | Number of Individuals Covered | 133 | | Insurance policy start date | 2012-03-01 | | Insurance policy end date | 2012-06-30 | | Total amount of commissions paid to insurance broker | USD $7,605 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $152,096 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,605 | | Insurance broker organization code? | 3 | | Insurance broker name | MJ INSURANCE, INC. |
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| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | 000010139926 |
| Policy instance | 1 |
| Insurance contract or identification number | 000010139926 | | Number of Individuals Covered | 141 | | Insurance policy start date | 2012-03-01 | | Insurance policy end date | 2013-02-28 | | Total amount of commissions paid to insurance broker | USD $299 | | Total amount of fees paid to insurance company | USD $37 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $1,992 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $299 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 37 | | Additional information about fees paid to insurance broker | BROKER BONUS | | Insurance broker name | MJ INSURANCE, INC. |
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| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 0716454 |
| Policy instance | 1 |
| Insurance contract or identification number | 0716454 | | Number of Individuals Covered | 123 | | Insurance policy start date | 2011-03-01 | | Insurance policy end date | 2012-02-29 | | Total amount of commissions paid to insurance broker | USD $33,840 | | Total amount of fees paid to insurance company | USD $1,926 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $563,970 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | 000010139926 |
| Policy instance | 2 |
| Insurance contract or identification number | 000010139926 | | Number of Individuals Covered | 133 | | Insurance policy start date | 2011-03-01 | | Insurance policy end date | 2012-02-29 | | Total amount of commissions paid to insurance broker | USD $298 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $1,987 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 302211 |
| Policy instance | 1 |
| Insurance contract or identification number | 302211 | | Number of Individuals Covered | 136 | | Insurance policy start date | 2010-03-01 | | Insurance policy end date | 2011-02-28 | | Total amount of commissions paid to insurance broker | USD $2,023 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $12,898 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,023 | | Insurance broker organization code? | 3 | | Insurance broker name | MJ INSURANCE INC. |
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| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 0716454 |
| Policy instance | 2 |
| Insurance contract or identification number | 0716454 | | Number of Individuals Covered | 197 | | Insurance policy start date | 2010-03-01 | | Insurance policy end date | 2011-02-28 | | Total amount of commissions paid to insurance broker | USD $43,471 | | Total amount of fees paid to insurance company | USD $6,488 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $727,729 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $43,471 | | Amount paid for insurance broker fees | 6488 | | Additional information about fees paid to insurance broker | BONUS AMOUNT | | Insurance broker organization code? | 3 | | Insurance broker name | MJ INSURANCE, INC. |
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