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GRAY AMERICA CORP. WELFARE BENEFIT PLAN 401k Plan overview

Plan NameGRAY AMERICA CORP. WELFARE BENEFIT PLAN
Plan identification number 501

GRAY AMERICA CORP. WELFARE BENEFIT PLAN Benefits

401k Plan TypeWelfare Benefit
Plan Features/Benefits
  • Health (other than dental or vision)
  • Life insurance
  • Dental
  • Vision
  • Temporary disability (accident and sickness)
  • Long-term disability cover
  • Death benefits (include travel accident but not life insurance)
  • Other welfare benefit cover

401k Sponsoring company profile

GRAY AMERICA CORP. has sponsored the creation of one or more 401k plans.

Company Name:GRAY AMERICA CORP.
Employer identification number (EIN):310943186
NAIC Classification:332900

Additional information about GRAY AMERICA CORP.

Jurisdiction of Incorporation: Ohio Secretary of State Business Services Division
Incorporation Date: 1978-10-05
Company Identification Number: 523873
Legal Registered Office Address: 41 SOUTH HIGH STREET
SUITE 2800
COLUMBUS
United States of America (USA)
43215

More information about GRAY AMERICA CORP.

Form 5500 Filing Information

Submission information for form 5500 for 401k plan GRAY AMERICA CORP. WELFARE BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5012022-01-01COURTNEY R. CARLISLE2023-10-12
5012021-01-01COURTNEY R. CARLISLE2022-10-13
5012020-01-01
5012019-01-01
5012019-01-01COURTNEY R. CARLISLE2023-10-12
5012018-01-01
5012018-01-01COURTNEY R. CARLISLE2023-10-12
5012017-01-01HOLLY GRAY HOLLY GRAY2018-10-10
5012017-01-01COURTNEY R. CARLISLE2023-10-12
5012016-01-01HOLLY GRAY HOLLY GRAY2017-08-21
5012016-01-01COURTNEY R. CARLISLE2023-10-12
5012015-01-01HOLLY GRAY HOLLY GRAY2017-05-16
5012015-01-01COURTNEY R. CARLISLE2023-10-12
5012014-01-01PAULINE M. OLON PAULINE M. OLON2015-07-31
5012013-01-01
5012012-01-01HOLLY GRAY
5012011-01-01HOLLY GRAY

Plan Statistics for GRAY AMERICA CORP. WELFARE BENEFIT PLAN

401k plan membership statisitcs for GRAY AMERICA CORP. WELFARE BENEFIT PLAN

Measure Date Value
2022: GRAY AMERICA CORP. WELFARE BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year2022-01-01127
Total number of active participants reported on line 7a of the Form 55002022-01-01120
Number of retired or separated participants receiving benefits2022-01-010
Number of other retired or separated participants entitled to future benefits2022-01-010
Total of all active and inactive participants2022-01-01120
Number of employers contributing to the scheme2022-01-010
2021: GRAY AMERICA CORP. WELFARE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year2021-01-01100
Total number of active participants reported on line 7a of the Form 55002021-01-01127
Number of retired or separated participants receiving benefits2021-01-010
Number of other retired or separated participants entitled to future benefits2021-01-010
Total of all active and inactive participants2021-01-01127
Number of employers contributing to the scheme2021-01-010
2020: GRAY AMERICA CORP. WELFARE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year2020-01-01104
Total number of active participants reported on line 7a of the Form 55002020-01-0184
Number of retired or separated participants receiving benefits2020-01-010
Number of other retired or separated participants entitled to future benefits2020-01-011
Total of all active and inactive participants2020-01-0185
2019: GRAY AMERICA CORP. WELFARE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year2019-01-01127
Total number of active participants reported on line 7a of the Form 55002019-01-01108
Number of retired or separated participants receiving benefits2019-01-010
Number of other retired or separated participants entitled to future benefits2019-01-011
Total of all active and inactive participants2019-01-01109
Number of employers contributing to the scheme2019-01-010
2018: GRAY AMERICA CORP. WELFARE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year2018-01-01125
Total number of active participants reported on line 7a of the Form 55002018-01-01127
Number of retired or separated participants receiving benefits2018-01-010
Number of other retired or separated participants entitled to future benefits2018-01-011
Total of all active and inactive participants2018-01-01128
Number of employers contributing to the scheme2018-01-010
2017: GRAY AMERICA CORP. WELFARE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year2017-01-01117
Total number of active participants reported on line 7a of the Form 55002017-01-01125
Number of retired or separated participants receiving benefits2017-01-010
Number of other retired or separated participants entitled to future benefits2017-01-010
Total of all active and inactive participants2017-01-01125
Number of employers contributing to the scheme2017-01-010
2016: GRAY AMERICA CORP. WELFARE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year2016-01-01106
Total number of active participants reported on line 7a of the Form 55002016-01-01117
Number of retired or separated participants receiving benefits2016-01-010
Number of other retired or separated participants entitled to future benefits2016-01-010
Total of all active and inactive participants2016-01-01117
Number of employers contributing to the scheme2016-01-010
2015: GRAY AMERICA CORP. WELFARE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year2015-01-01128
Total number of active participants reported on line 7a of the Form 55002015-01-01106
Number of retired or separated participants receiving benefits2015-01-011
Number of other retired or separated participants entitled to future benefits2015-01-013
Total of all active and inactive participants2015-01-01110
Total participants2015-01-01110
Number of employers contributing to the scheme2015-01-010
2014: GRAY AMERICA CORP. WELFARE BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year2014-01-0189
Total number of active participants reported on line 7a of the Form 55002014-01-0191
Number of retired or separated participants receiving benefits2014-01-011
Number of other retired or separated participants entitled to future benefits2014-01-0117
Total of all active and inactive participants2014-01-01109
2013: GRAY AMERICA CORP. WELFARE BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year2013-01-01115
Total number of active participants reported on line 7a of the Form 55002013-01-01118
Total of all active and inactive participants2013-01-01118
2012: GRAY AMERICA CORP. WELFARE BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year2012-01-01109
Total number of active participants reported on line 7a of the Form 55002012-01-01115
Total of all active and inactive participants2012-01-01115
2011: GRAY AMERICA CORP. WELFARE BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year2011-01-01102
Total number of active participants reported on line 7a of the Form 55002011-01-01108
Number of other retired or separated participants entitled to future benefits2011-01-011
Total of all active and inactive participants2011-01-01109

Form 5500 Responses for GRAY AMERICA CORP. WELFARE BENEFIT PLAN

2022: GRAY AMERICA CORP. WELFARE BENEFIT PLAN 2022 form 5500 responses
2022-01-01Type of plan entitySingle employer plan
2022-01-01Plan funding arrangement – InsuranceYes
2022-01-01Plan benefit arrangement – InsuranceYes
2021: GRAY AMERICA CORP. WELFARE BENEFIT PLAN 2021 form 5500 responses
2021-01-01Type of plan entitySingle employer plan
2021-01-01Plan funding arrangement – InsuranceYes
2021-01-01Plan benefit arrangement – InsuranceYes
2020: GRAY AMERICA CORP. WELFARE BENEFIT PLAN 2020 form 5500 responses
2020-01-01Type of plan entitySingle employer plan
2020-01-01Plan funding arrangement – InsuranceYes
2020-01-01Plan funding arrangement – General assets of the sponsorYes
2020-01-01Plan benefit arrangement – InsuranceYes
2020-01-01Plan benefit arrangement – General assets of the sponsorYes
2019: GRAY AMERICA CORP. WELFARE BENEFIT PLAN 2019 form 5500 responses
2019-01-01Type of plan entitySingle employer plan
2019-01-01Submission has been amendedYes
2019-01-01Plan funding arrangement – InsuranceYes
2019-01-01Plan funding arrangement – General assets of the sponsorYes
2019-01-01Plan benefit arrangement – InsuranceYes
2019-01-01Plan benefit arrangement – General assets of the sponsorYes
2018: GRAY AMERICA CORP. WELFARE BENEFIT PLAN 2018 form 5500 responses
2018-01-01Type of plan entitySingle employer plan
2018-01-01Submission has been amendedYes
2018-01-01Plan funding arrangement – InsuranceYes
2018-01-01Plan funding arrangement – General assets of the sponsorYes
2018-01-01Plan benefit arrangement – InsuranceYes
2018-01-01Plan benefit arrangement – General assets of the sponsorYes
2017: GRAY AMERICA CORP. WELFARE BENEFIT PLAN 2017 form 5500 responses
2017-01-01Type of plan entitySingle employer plan
2017-01-01Submission has been amendedYes
2017-01-01Plan funding arrangement – InsuranceYes
2017-01-01Plan funding arrangement – General assets of the sponsorYes
2017-01-01Plan benefit arrangement – InsuranceYes
2017-01-01Plan benefit arrangement – General assets of the sponsorYes
2016: GRAY AMERICA CORP. WELFARE BENEFIT PLAN 2016 form 5500 responses
2016-01-01Type of plan entitySingle employer plan
2016-01-01Submission has been amendedYes
2016-01-01Plan funding arrangement – InsuranceYes
2016-01-01Plan funding arrangement – General assets of the sponsorYes
2016-01-01Plan benefit arrangement – InsuranceYes
2016-01-01Plan benefit arrangement – General assets of the sponsorYes
2015: GRAY AMERICA CORP. WELFARE BENEFIT PLAN 2015 form 5500 responses
2015-01-01Type of plan entitySingle employer plan
2015-01-01Submission has been amendedYes
2015-01-01Plan funding arrangement – InsuranceYes
2015-01-01Plan funding arrangement – General assets of the sponsorYes
2015-01-01Plan benefit arrangement – InsuranceYes
2015-01-01Plan benefit arrangement – General assets of the sponsorYes
2014: GRAY AMERICA CORP. WELFARE BENEFIT PLAN 2014 form 5500 responses
2014-01-01Type of plan entitySingle employer plan
2014-01-01Submission has been amendedNo
2014-01-01This submission is the final filingNo
2014-01-01This return/report is a short plan year return/report (less than 12 months)No
2014-01-01Plan is a collectively bargained planNo
2014-01-01Plan funding arrangement – InsuranceYes
2014-01-01Plan funding arrangement – General assets of the sponsorYes
2014-01-01Plan benefit arrangement – InsuranceYes
2014-01-01Plan benefit arrangement – General assets of the sponsorYes
2013: GRAY AMERICA CORP. WELFARE BENEFIT PLAN 2013 form 5500 responses
2013-01-01Type of plan entitySingle employer plan
2013-01-01Plan funding arrangement – InsuranceYes
2013-01-01Plan funding arrangement – General assets of the sponsorYes
2013-01-01Plan benefit arrangement – InsuranceYes
2013-01-01Plan benefit arrangement – General assets of the sponsorYes
2012: GRAY AMERICA CORP. WELFARE BENEFIT PLAN 2012 form 5500 responses
2012-01-01Type of plan entitySingle employer plan
2012-01-01Plan funding arrangement – InsuranceYes
2012-01-01Plan benefit arrangement – InsuranceYes
2011: GRAY AMERICA CORP. WELFARE BENEFIT PLAN 2011 form 5500 responses
2011-01-01Type of plan entitySingle employer plan
2011-01-01Plan funding arrangement – InsuranceYes
2011-01-01Plan benefit arrangement – InsuranceYes

Insurance Providers Used on plan

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGVTL0306K
Policy instance 4
Insurance contract or identification numberGVTL0306K
Number of Individuals Covered120
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $8,873
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $70,516
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $7,397
Amount paid for insurance broker fees0
Insurance broker organization code?3
AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 )
Policy contract number25504
Policy instance 3
Insurance contract or identification number25504
Number of Individuals Covered40
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $1,858
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedACCIDENT, CRITICAL ILLNESS, CANCER
Welfare Benefit Premiums Paid to CarrierUSD $12,207
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,274
Amount paid for insurance broker fees0
Insurance broker organization code?3
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number922893
Policy instance 2
Insurance contract or identification number922893
Number of Individuals Covered76
Insurance policy start date2022-03-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $668
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $6,677
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $661
Amount paid for insurance broker fees0
Insurance broker organization code?3
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number922893
Policy instance 1
Insurance contract or identification number922893
Number of Individuals Covered174
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $2,667
Total amount of fees paid to insurance companyUSD $28,388
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,037,672
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,200
Amount paid for insurance broker fees23101
Additional information about fees paid to insurance brokerSERVICE FEE AGREEMENT
Insurance broker organization code?3
AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 )
Policy contract number25504
Policy instance 2
Insurance contract or identification number25504
Number of Individuals Covered21
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $666
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedACCIDENT, CRITICAL ILLNESS, CANCER
Welfare Benefit Premiums Paid to CarrierUSD $10,569
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $505
Amount paid for insurance broker fees0
Insurance broker organization code?3
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number922893
Policy instance 1
Insurance contract or identification number922893
Number of Individuals Covered92
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $33,904
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $794,701
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $0
Amount paid for insurance broker fees33904
Additional information about fees paid to insurance brokerSERVICE FEE AGREEEMENT, BONUS
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGVTL0306K
Policy instance 3
Insurance contract or identification numberGVTL0306K
Number of Individuals Covered127
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $9,390
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $75,774
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $9,390
Amount paid for insurance broker fees0
Insurance broker organization code?3
SUPERIOR DENTAL CARE, INC. (National Association of Insurance Commissioners NAIC id number: 96280 )
Policy contract numberD4598
Policy instance 1
Insurance contract or identification numberD4598
Number of Individuals Covered154
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $3,120
Dental Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,120
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGVTL0306K
Policy instance 2
Insurance contract or identification numberGVTL0306K
Number of Individuals Covered59
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $4,729
Other welfare benefits providedVOLUNTARY LIFE
Welfare Benefit Premiums Paid to CarrierUSD $31,526
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,729
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGUG0306K
Policy instance 3
Insurance contract or identification numberGUG0306K
Number of Individuals Covered85
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $2,010
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $20,105
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,010
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLTD0306K
Policy instance 4
Insurance contract or identification numberGLTD0306K
Number of Individuals Covered33
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $1,125
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $7,498
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,125
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLLV0306K
Policy instance 5
Insurance contract or identification numberGLLV0306K
Number of Individuals Covered66
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $745
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $8,271
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $745
Insurance broker organization code?3
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number01X0198
Policy instance 6
Insurance contract or identification number01X0198
Number of Individuals Covered185
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $40,320
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $885,055
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $40,320
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLUG0306K
Policy instance 7
Insurance contract or identification numberGLUG0306K
Number of Individuals Covered117
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $806
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $8,062
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $806
Insurance broker organization code?3
AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 )
Policy contract number25504
Policy instance 8
Insurance contract or identification number25504
Number of Individuals Covered25
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $243
Total amount of fees paid to insurance companyUSD $38
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $4,352
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $234
Amount paid for insurance broker fees38
Insurance broker organization code?3
AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 )
Policy contract number25504
Policy instance 9
Insurance contract or identification number25504
Number of Individuals Covered14
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $454
Total amount of fees paid to insurance companyUSD $22
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $3,668
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $219
Amount paid for insurance broker fees22
Insurance broker organization code?3
AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 )
Policy contract number25504
Policy instance 10
Insurance contract or identification number25504
Number of Individuals Covered10
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $166
Total amount of fees paid to insurance companyUSD $17
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $2,591
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $163
Amount paid for insurance broker fees17
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number01X0198
Policy instance 1
Insurance contract or identification number01X0198
Number of Individuals Covered197
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $25,872
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $996,686
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $25,872
Amount paid for insurance broker fees0
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLUG0306K
Policy instance 5
Insurance contract or identification numberGLUG0306K
Number of Individuals Covered141
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $8,934
Total amount of fees paid to insurance companyUSD $3,446
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $67,598
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,918
Amount paid for insurance broker fees3446
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
SUPERIOR DENTAL CARE, INC. (National Association of Insurance Commissioners NAIC id number: 96280 )
Policy contract numberD4598
Policy instance 1
Insurance contract or identification numberD4598
Number of Individuals Covered180
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $3,122
Dental Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,073
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGVTL0306K
Policy instance 2
Insurance contract or identification numberGVTL0306K
Number of Individuals Covered87
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $5,552
Total amount of fees paid to insurance companyUSD $1,917
Other welfare benefits providedVOLUNTARY LIFE
Welfare Benefit Premiums Paid to CarrierUSD $37,011
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,704
Amount paid for insurance broker fees1917
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLTD0306K
Policy instance 4
Insurance contract or identification numberGLTD0306K
Number of Individuals Covered37
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $972
Total amount of fees paid to insurance companyUSD $353
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $6,479
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $637
Amount paid for insurance broker fees353
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number9803981001
Policy instance 5
Insurance contract or identification number9803981001
Number of Individuals Covered163
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $1,018
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $10,287
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $755
Insurance broker organization code?3
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number01X0198
Policy instance 6
Insurance contract or identification number01X0198
Number of Individuals Covered197
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $25,872
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $996,686
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $25,872
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLUG0306K
Policy instance 7
Insurance contract or identification numberGLUG0306K
Number of Individuals Covered141
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $779
Total amount of fees paid to insurance companyUSD $395
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $7,793
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $513
Amount paid for insurance broker fees395
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 )
Policy contract number25504
Policy instance 4
Insurance contract or identification number25504
Number of Individuals Covered29
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $2,546
Total amount of fees paid to insurance companyUSD $151
Other welfare benefits providedACCIDENT, CRITICAL ILLNESS, CANCER
Welfare Benefit Premiums Paid to CarrierUSD $12,932
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,546
Amount paid for insurance broker fees151
Additional information about fees paid to insurance brokerSUPPLEMENTAL COMPENSATION
Insurance broker organization code?3
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number9803981001
Policy instance 3
Insurance contract or identification number9803981001
Number of Individuals Covered163
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $1,018
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $10,287
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $755
Amount paid for insurance broker fees0
Insurance broker organization code?3
SUPERIOR DENTAL CARE, INC. (National Association of Insurance Commissioners NAIC id number: 96280 )
Policy contract numberD4598
Policy instance 2
Insurance contract or identification numberD4598
Number of Individuals Covered180
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $3,122
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,073
Amount paid for insurance broker fees0
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGUG0306K
Policy instance 3
Insurance contract or identification numberGUG0306K
Number of Individuals Covered104
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $1,631
Total amount of fees paid to insurance companyUSD $781
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $16,315
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,064
Amount paid for insurance broker fees781
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
SUPERIOR DENTAL CARE, INC. (National Association of Insurance Commissioners NAIC id number: 96280 )
Policy contract numberD4598
Policy instance 2
Insurance contract or identification numberD4598
Number of Individuals Covered166
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $2,899
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,899
Amount paid for insurance broker fees0
Insurance broker organization code?3
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number9803981001
Policy instance 3
Insurance contract or identification number9803981001
Number of Individuals Covered147
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $877
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $8,792
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $877
Amount paid for insurance broker fees0
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLUG0306K
Policy instance 5
Insurance contract or identification numberGLUG0306K
Number of Individuals Covered129
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $8,436
Total amount of fees paid to insurance companyUSD $3,765
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $63,481
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $8,436
Amount paid for insurance broker fees3765
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 )
Policy contract number25504
Policy instance 4
Insurance contract or identification number25504
Number of Individuals Covered26
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $955
Total amount of fees paid to insurance companyUSD $328
Other welfare benefits providedACCIDENT, CRITICAL ILLNESS, CANCER
Welfare Benefit Premiums Paid to CarrierUSD $9,931
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $955
Amount paid for insurance broker fees328
Additional information about fees paid to insurance brokerSUPPLEMENTAL COMPENSATION
Insurance broker organization code?3
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number720218
Policy instance 1
Insurance contract or identification number720218
Number of Individuals Covered185
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $33,908
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $889,253
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $33,908
Amount paid for insurance broker fees0
Insurance broker organization code?3
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number9803981001
Policy instance 5
Insurance contract or identification number9803981001
Number of Individuals Covered147
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $877
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $8,792
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $877
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGVTL0306K
Policy instance 2
Insurance contract or identification numberGVTL0306K
Number of Individuals Covered77
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $5,274
Total amount of fees paid to insurance companyUSD $2,001
Other welfare benefits providedVOLUNTARY LIFE
Welfare Benefit Premiums Paid to CarrierUSD $35,159
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,274
Amount paid for insurance broker fees2001
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number720218
Policy instance 6
Insurance contract or identification number720218
Number of Individuals Covered185
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $33,908
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $889,253
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $33,908
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLUG0306K
Policy instance 7
Insurance contract or identification numberGLUG0306K
Number of Individuals Covered129
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $733
Total amount of fees paid to insurance companyUSD $443
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $7,327
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $733
Amount paid for insurance broker fees443
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLTD0306K
Policy instance 4
Insurance contract or identification numberGLTD0306K
Number of Individuals Covered35
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $987
Total amount of fees paid to insurance companyUSD $412
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $6,578
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $987
Amount paid for insurance broker fees412
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
SUPERIOR DENTAL CARE, INC. (National Association of Insurance Commissioners NAIC id number: 96280 )
Policy contract numberD4598
Policy instance 1
Insurance contract or identification numberD4598
Number of Individuals Covered166
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $2,899
Dental Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,899
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGUG0306K
Policy instance 3
Insurance contract or identification numberGUG0306K
Number of Individuals Covered94
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $1,442
Total amount of fees paid to insurance companyUSD $909
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $14,417
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,442
Amount paid for insurance broker fees909
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
SUPERIOR DENTAL CARE, INC. (National Association of Insurance Commissioners NAIC id number: 96280 )
Policy contract numberD4598
Policy instance 2
Insurance contract or identification numberD4598
Number of Individuals Covered169
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $3,000
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,000
Amount paid for insurance broker fees0
Insurance broker organization code?3
SUPERIOR DENTAL CARE, INC. (National Association of Insurance Commissioners NAIC id number: 96280 )
Policy contract numberD4598
Policy instance 1
Insurance contract or identification numberD4598
Number of Individuals Covered169
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $3,000
Dental Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,000
Insurance broker organization code?3
Insurance broker nameMARSH & MCLENNAN AGENCY, LLC
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGVTL0306K
Policy instance 2
Insurance contract or identification numberGVTL0306K
Number of Individuals Covered73
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $4,998
Total amount of fees paid to insurance companyUSD $2,680
Other welfare benefits providedVOLUNTARY LIFE
Welfare Benefit Premiums Paid to CarrierUSD $33,317
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,998
Amount paid for insurance broker fees2680
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
Insurance broker nameMARSH & MCLENNAN AGENCY LLC
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGUG0306K
Policy instance 3
Insurance contract or identification numberGUG0306K
Number of Individuals Covered90
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $1,505
Total amount of fees paid to insurance companyUSD $1,229
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $15,049
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,505
Amount paid for insurance broker fees1229
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
Insurance broker nameMARSH & MCLENNAN AGENCY LLC
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLTD0306K
Policy instance 4
Insurance contract or identification numberGLTD0306K
Number of Individuals Covered35
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $1,022
Total amount of fees paid to insurance companyUSD $630
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $6,816
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,022
Amount paid for insurance broker fees630
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
Insurance broker nameMARSH & MCLENNAN AGENCY LLC
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number9803981001
Policy instance 5
Insurance contract or identification number9803981001
Number of Individuals Covered141
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $915
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $9,895
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $915
Insurance broker organization code?3
Insurance broker nameMARSH & MCLENNAN AGENCY
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number720218
Policy instance 6
Insurance contract or identification number720218
Number of Individuals Covered175
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $29,204
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $838,212
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $29,204
Insurance broker organization code?3
Insurance broker nameMARSH & MCLENNAN AGENCY
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLUG0306K
Policy instance 5
Insurance contract or identification numberGLUG0306K
Number of Individuals Covered125
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $8,260
Total amount of fees paid to insurance companyUSD $5,539
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $62,535
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $8,260
Amount paid for insurance broker fees5539
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number720218
Policy instance 1
Insurance contract or identification number720218
Number of Individuals Covered175
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $29,204
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $838,212
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $29,204
Amount paid for insurance broker fees0
Insurance broker organization code?3
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number9803981001
Policy instance 3
Insurance contract or identification number9803981001
Number of Individuals Covered141
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $915
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $9,895
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $915
Amount paid for insurance broker fees0
Insurance broker organization code?3
AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 )
Policy contract number25504
Policy instance 4
Insurance contract or identification number25504
Number of Individuals Covered23
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $3,953
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedACCIDENT, CRITICAL ILLNESS, CANCER
Welfare Benefit Premiums Paid to CarrierUSD $11,427
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,953
Amount paid for insurance broker fees0
Insurance broker organization code?3
SUPERIOR DENTAL CARE, INC. (National Association of Insurance Commissioners NAIC id number: 96280 )
Policy contract numberD4598
Policy instance 2
Insurance contract or identification numberD4598
Number of Individuals Covered165
Insurance policy start date2016-01-01
Insurance policy end date2016-12-31
Total amount of commissions paid to insurance brokerUSD $2,781
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,781
Amount paid for insurance broker fees0
Insurance broker organization code?3
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number9803981001
Policy instance 3
Insurance contract or identification number9803981001
Number of Individuals Covered132
Insurance policy start date2016-01-01
Insurance policy end date2016-12-31
Total amount of commissions paid to insurance brokerUSD $762
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $7,581
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $762
Amount paid for insurance broker fees0
Insurance broker organization code?3
UNITED HEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number170134
Policy instance 4
Insurance contract or identification number170134
Number of Individuals Covered117
Insurance policy start date2016-01-01
Insurance policy end date2016-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Life Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 )
Policy contract number25504
Policy instance 5
Insurance contract or identification number25504
Number of Individuals Covered117
Insurance policy start date2016-01-01
Insurance policy end date2016-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedACCIDENT, CRITICAL ILLNESS, CANCER
Welfare Benefit Premiums Paid to CarrierUSD $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 )
Policy contract numberG1400
Policy instance 6
Insurance contract or identification numberG1400
Number of Individuals Covered127
Insurance policy start date2016-01-01
Insurance policy end date2016-12-31
Total amount of commissions paid to insurance brokerUSD $697
Total amount of fees paid to insurance companyUSD $0
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $6,966
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $697
Amount paid for insurance broker fees0
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGVTL0306K
Policy instance 7
Insurance contract or identification numberGVTL0306K
Number of Individuals Covered117
Insurance policy start date2016-01-01
Insurance policy end date2016-12-31
Total amount of commissions paid to insurance brokerUSD $6,887
Total amount of fees paid to insurance companyUSD $4,485
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Welfare Benefit Premiums Paid to CarrierUSD $50,491
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6,887
Amount paid for insurance broker fees4485
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
COMMUNITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 10345 )
Policy contract numberG1728
Policy instance 1
Insurance contract or identification numberG1728
Number of Individuals Covered168
Insurance policy start date2016-01-01
Insurance policy end date2016-12-31
Total amount of commissions paid to insurance brokerUSD $23,060
Total amount of fees paid to insurance companyUSD $748
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $866,458
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $23,060
Amount paid for insurance broker fees748
Additional information about fees paid to insurance brokerINCENTIVES, EDUCATION, COMMUNICATION AND TRAINING
Insurance broker organization code?3
COMMUNITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 10345 )
Policy contract numberG1728
Policy instance 1
Insurance contract or identification numberG1728
Number of Individuals Covered139
Insurance policy start date2015-01-01
Insurance policy end date2015-12-31
Total amount of commissions paid to insurance brokerUSD $29,931
Total amount of fees paid to insurance companyUSD $4,874
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $908,579
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $29,927
Amount paid for insurance broker fees2374
Additional information about fees paid to insurance brokerINCENTIVES, EDUCATION, COMMUNICATION AND TRAINING
Insurance broker organization code?3
SUPERIOR DENTAL CARE, INC. (National Association of Insurance Commissioners NAIC id number: 96280 )
Policy contract numberD4598
Policy instance 2
Insurance contract or identification numberD4598
Number of Individuals Covered181
Insurance policy start date2015-01-01
Insurance policy end date2015-12-31
Total amount of commissions paid to insurance brokerUSD $3,150
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,150
Amount paid for insurance broker fees0
Insurance broker organization code?3
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number9803981001
Policy instance 3
Insurance contract or identification number9803981001
Number of Individuals Covered132
Insurance policy start date2015-01-01
Insurance policy end date2015-12-31
Total amount of commissions paid to insurance brokerUSD $916
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $9,109
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $916
Amount paid for insurance broker fees0
Insurance broker organization code?3
UNITED HEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number172468
Policy instance 4
Insurance contract or identification number172468
Number of Individuals Covered110
Insurance policy start date2015-01-01
Insurance policy end date2015-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Life Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 )
Policy contract number25504
Policy instance 5
Insurance contract or identification number25504
Number of Individuals Covered110
Insurance policy start date2015-01-01
Insurance policy end date2015-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedACCIDENT, CRITICAL ILLNESS, CANCER
Welfare Benefit Premiums Paid to CarrierUSD $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGVTL0306K
Policy instance 6
Insurance contract or identification numberGVTL0306K
Number of Individuals Covered86
Insurance policy start date2015-01-01
Insurance policy end date2015-12-31
Total amount of commissions paid to insurance brokerUSD $6,741
Total amount of fees paid to insurance companyUSD $4,249
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Welfare Benefit Premiums Paid to CarrierUSD $49,830
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6,741
Amount paid for insurance broker fees4249
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3

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