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COSHOCTON COUNTY MEMORIAL HOSPITAL EMPLOYEE HEALTH BENEFIT PLAN 401k Plan overview

Plan NameCOSHOCTON COUNTY MEMORIAL HOSPITAL EMPLOYEE HEALTH BENEFIT PLAN
Plan identification number 501

COSHOCTON COUNTY MEMORIAL HOSPITAL EMPLOYEE HEALTH BENEFIT PLAN Benefits

401k Plan TypeWelfare Benefit
Plan Features/Benefits
  • Health (other than dental or vision)
  • Life insurance
  • Vision
  • Long-term disability cover

401k Sponsoring company profile

COSHOCTON COUNTY MEMORIAL HOSPITAL ASSOCIATION, INC. has sponsored the creation of one or more 401k plans.

Company Name:COSHOCTON COUNTY MEMORIAL HOSPITAL ASSOCIATION, INC.
Employer identification number (EIN):314387577
NAIC Classification:622000
NAIC Description: Hospitals

Form 5500 Filing Information

Submission information for form 5500 for 401k plan COSHOCTON COUNTY MEMORIAL HOSPITAL EMPLOYEE HEALTH BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5012015-01-01
5012014-01-01SCOTT SILVERSTRI
5012013-01-01SCOTT SILVERSTRI
5012012-01-01RICHARD K. DAVIS
5012011-01-01RICHARD K. DAVIS
5012009-01-01RICHARD K. DAVIS

Plan Statistics for COSHOCTON COUNTY MEMORIAL HOSPITAL EMPLOYEE HEALTH BENEFIT PLAN

401k plan membership statisitcs for COSHOCTON COUNTY MEMORIAL HOSPITAL EMPLOYEE HEALTH BENEFIT PLAN

Measure Date Value
2015: COSHOCTON COUNTY MEMORIAL HOSPITAL EMPLOYEE HEALTH BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year2015-01-01363
Total number of active participants reported on line 7a of the Form 55002015-01-01309
Number of retired or separated participants receiving benefits2015-01-010
Number of other retired or separated participants entitled to future benefits2015-01-010
Total of all active and inactive participants2015-01-01309
2014: COSHOCTON COUNTY MEMORIAL HOSPITAL EMPLOYEE HEALTH BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year2014-01-01451
Total number of active participants reported on line 7a of the Form 55002014-01-01363
Number of retired or separated participants receiving benefits2014-01-010
Number of other retired or separated participants entitled to future benefits2014-01-010
Total of all active and inactive participants2014-01-01363
2013: COSHOCTON COUNTY MEMORIAL HOSPITAL EMPLOYEE HEALTH BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year2013-01-01458
Total number of active participants reported on line 7a of the Form 55002013-01-01478
Number of retired or separated participants receiving benefits2013-01-010
Number of other retired or separated participants entitled to future benefits2013-01-010
Total of all active and inactive participants2013-01-01478
2012: COSHOCTON COUNTY MEMORIAL HOSPITAL EMPLOYEE HEALTH BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year2012-01-01480
Total number of active participants reported on line 7a of the Form 55002012-01-01458
Number of retired or separated participants receiving benefits2012-01-010
Number of other retired or separated participants entitled to future benefits2012-01-010
Total of all active and inactive participants2012-01-01458
2011: COSHOCTON COUNTY MEMORIAL HOSPITAL EMPLOYEE HEALTH BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year2011-01-01398
Total number of active participants reported on line 7a of the Form 55002011-01-01480
Number of retired or separated participants receiving benefits2011-01-010
Number of other retired or separated participants entitled to future benefits2011-01-010
Total of all active and inactive participants2011-01-01480
2009: COSHOCTON COUNTY MEMORIAL HOSPITAL EMPLOYEE HEALTH BENEFIT PLAN 2009 401k membership
Total participants, beginning-of-year2009-01-01423
Total number of active participants reported on line 7a of the Form 55002009-01-01436
Number of retired or separated participants receiving benefits2009-01-010
Number of other retired or separated participants entitled to future benefits2009-01-010
Total of all active and inactive participants2009-01-01436

Financial Data on COSHOCTON COUNTY MEMORIAL HOSPITAL EMPLOYEE HEALTH BENEFIT PLAN

Measure Date Value
2013 : COSHOCTON COUNTY MEMORIAL HOSPITAL EMPLOYEE HEALTH BENEFIT PLAN 2013 401k financial data
Total income from all sources2013-12-31$676,102
Expenses. Total of all expenses incurred2013-12-31$676,102
Benefits paid (including direct rollovers)2013-12-31$676,102
Value of fidelity bond covering the plan2013-12-31$50,000
Net income (gross income less expenses)2013-12-31$0
Net plan assets at end of year (total assets less liabilities)2013-12-31$0
Net plan assets at beginning of year (total assets less liabilities)2013-12-31$0
Total contributions received or receivable from employer(s)2013-12-31$676,102
2012 : COSHOCTON COUNTY MEMORIAL HOSPITAL EMPLOYEE HEALTH BENEFIT PLAN 2012 401k financial data
Total income from all sources2012-12-31$718,273
Expenses. Total of all expenses incurred2012-12-31$718,273
Benefits paid (including direct rollovers)2012-12-31$718,273
Value of fidelity bond covering the plan2012-12-31$50,000
Net income (gross income less expenses)2012-12-31$0
Net plan assets at end of year (total assets less liabilities)2012-12-31$0
Net plan assets at beginning of year (total assets less liabilities)2012-12-31$0
Total contributions received or receivable from employer(s)2012-12-31$718,273
2011 : COSHOCTON COUNTY MEMORIAL HOSPITAL EMPLOYEE HEALTH BENEFIT PLAN 2011 401k financial data
Total income from all sources2011-12-31$709,729
Expenses. Total of all expenses incurred2011-12-31$709,729
Benefits paid (including direct rollovers)2011-12-31$709,729
Value of fidelity bond covering the plan2011-12-31$50,000
Total contributions received or receivable from participants2011-12-31$2,648
Net income (gross income less expenses)2011-12-31$0
Net plan assets at end of year (total assets less liabilities)2011-12-31$0
Net plan assets at beginning of year (total assets less liabilities)2011-12-31$0
Total contributions received or receivable from employer(s)2011-12-31$707,081
2010 : COSHOCTON COUNTY MEMORIAL HOSPITAL EMPLOYEE HEALTH BENEFIT PLAN 2010 401k financial data
Total income from all sources2010-12-31$3,602,590
Expenses. Total of all expenses incurred2010-12-31$3,602,590
Benefits paid (including direct rollovers)2010-12-31$3,602,590
Total contributions received or receivable from participants2010-12-31$252,590
Net income (gross income less expenses)2010-12-31$0
Net plan assets at end of year (total assets less liabilities)2010-12-31$0
Net plan assets at beginning of year (total assets less liabilities)2010-12-31$0
Total contributions received or receivable from employer(s)2010-12-31$3,350,000

Form 5500 Responses for COSHOCTON COUNTY MEMORIAL HOSPITAL EMPLOYEE HEALTH BENEFIT PLAN

2015: COSHOCTON COUNTY MEMORIAL HOSPITAL EMPLOYEE HEALTH BENEFIT PLAN 2015 form 5500 responses
2015-01-01Type of plan entitySingle employer plan
2015-01-01Submission has been amendedNo
2015-01-01This submission is the final filingNo
2015-01-01This return/report is a short plan year return/report (less than 12 months)No
2015-01-01Plan is a collectively bargained planNo
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: COSHOCTON COUNTY MEMORIAL HOSPITAL EMPLOYEE HEALTH 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: COSHOCTON COUNTY MEMORIAL HOSPITAL EMPLOYEE HEALTH BENEFIT PLAN 2013 form 5500 responses
2013-01-01Type of plan entitySingle employer plan
2013-01-01Submission has been amendedNo
2013-01-01This submission is the final filingNo
2013-01-01This return/report is a short plan year return/report (less than 12 months)No
2013-01-01Plan is a collectively bargained planNo
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: COSHOCTON COUNTY MEMORIAL HOSPITAL EMPLOYEE HEALTH BENEFIT PLAN 2012 form 5500 responses
2012-01-01Type of plan entitySingle employer plan
2012-01-01Submission has been amendedNo
2012-01-01This submission is the final filingNo
2012-01-01This return/report is a short plan year return/report (less than 12 months)No
2012-01-01Plan is a collectively bargained planNo
2012-01-01Plan funding arrangement – InsuranceYes
2012-01-01Plan funding arrangement – General assets of the sponsorYes
2012-01-01Plan benefit arrangement – InsuranceYes
2012-01-01Plan benefit arrangement – General assets of the sponsorYes
2011: COSHOCTON COUNTY MEMORIAL HOSPITAL EMPLOYEE HEALTH BENEFIT PLAN 2011 form 5500 responses
2011-01-01Type of plan entitySingle employer plan
2011-01-01Submission has been amendedNo
2011-01-01This submission is the final filingNo
2011-01-01This return/report is a short plan year return/report (less than 12 months)No
2011-01-01Plan is a collectively bargained planNo
2011-01-01Plan funding arrangement – InsuranceYes
2011-01-01Plan benefit arrangement – InsuranceYes
2009: COSHOCTON COUNTY MEMORIAL HOSPITAL EMPLOYEE HEALTH BENEFIT PLAN 2009 form 5500 responses
2009-01-01Type of plan entitySingle employer plan
2009-01-01Submission has been amendedNo
2009-01-01This submission is the final filingNo
2009-01-01This return/report is a short plan year return/report (less than 12 months)No
2009-01-01Plan is a collectively bargained planNo
2009-01-01Plan funding arrangement – InsuranceYes
2009-01-01Plan benefit arrangement – InsuranceYes

Insurance Providers Used on plan

NATIONAL UNION (National Association of Insurance Commissioners NAIC id number: 19445 )
Policy contract number10042
Policy instance 1
Insurance contract or identification number10042
Number of Individuals Covered309
Insurance policy start date2015-01-01
Insurance policy end date2015-12-31
Total amount of commissions paid to insurance brokerUSD $64,470
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $365,329
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $34,384
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerBROKER
Insurance broker organization code?5
Insurance broker nameMEDICAL BENEFITS ADMINISTRATORS
VISION COVERAGE VISIONPLUS OF AMERICA (National Association of Insurance Commissioners NAIC id number: 74322 )
Policy contract number10042
Policy instance 2
Insurance contract or identification number10042
Number of Individuals Covered11
Insurance policy start date2015-01-01
Insurance policy end date2015-12-31
Total amount of commissions paid to insurance brokerUSD $13
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $177
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $13
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerBROKER
Insurance broker organization code?3
Insurance broker nameRANKIN & RANKIN
AIG MEDICAL EXCESS (National Association of Insurance Commissioners NAIC id number: 19445 )
Policy contract number10042
Policy instance 1
Insurance contract or identification number10042
Number of Individuals Covered363
Insurance policy start date2014-01-01
Insurance policy end date2014-12-31
Total amount of commissions paid to insurance brokerUSD $65,167
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $369,503
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $34,765
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerBROKER
Insurance broker organization code?5
Insurance broker nameMEDICAL BENEFITS ADMINISTRATORS
VISION COVERAGE VISIONPLUS OF AMERICA (National Association of Insurance Commissioners NAIC id number: 74322 )
Policy contract number10042
Policy instance 2
Insurance contract or identification number10042
Number of Individuals Covered5
Insurance policy start date2014-01-01
Insurance policy end date2014-12-31
Total amount of commissions paid to insurance brokerUSD $4
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $46
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerBROKER
Insurance broker organization code?5
Insurance broker nameRANKIN & RANKIN
AIG MEDICAL EXCESS (National Association of Insurance Commissioners NAIC id number: 19445 )
Policy contract number10042
Policy instance 1
Insurance contract or identification number10042
Number of Individuals Covered478
Insurance policy start date2013-01-01
Insurance policy end date2013-12-31
Total amount of commissions paid to insurance brokerUSD $61,264
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $347,162
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $32,674
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerBROKER
Insurance broker organization code?3
Insurance broker nameMEDICAL BENEFITS ADMINISTRATORS
VISION COVERAGE VISIONPLUS OF AMERICA (National Association of Insurance Commissioners NAIC id number: 74322 )
Policy contract number10042
Policy instance 2
Insurance contract or identification number10042
Number of Individuals Covered478
Insurance policy start date2013-01-01
Insurance policy end date2013-12-31
Total amount of commissions paid to insurance brokerUSD $4,067
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $54,872
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,067
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerBROKER
Insurance broker organization code?5
Insurance broker nameRANKIN & RANKIN
AIG MEDICAL EXCESS (National Association of Insurance Commissioners NAIC id number: 19445 )
Policy contract number10042
Policy instance 1
Insurance contract or identification number10042
Number of Individuals Covered458
Insurance policy start date2012-01-01
Insurance policy end date2012-12-31
Total amount of commissions paid to insurance brokerUSD $56,798
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $301,740
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $28,399
Insurance broker organization code?3
Insurance broker nameMEDICAL BENEFITS ADMINISTRATORS
VISION COVERAGE VISIONPLUS OF AMERICA (National Association of Insurance Commissioners NAIC id number: 74322 )
Policy contract number10042
Policy instance 2
Insurance contract or identification number10042
Number of Individuals Covered458
Insurance policy start date2012-01-01
Insurance policy end date2012-12-31
Total amount of commissions paid to insurance brokerUSD $6,380
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $86,079
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6,380
Insurance broker organization code?5
Insurance broker nameRANKIN & RANKIN
AIG MEDICAL EXCESS (National Association of Insurance Commissioners NAIC id number: 19445 )
Policy contract number10042
Policy instance 1
Insurance contract or identification number10042
Number of Individuals Covered480
Insurance policy start date2011-01-01
Insurance policy end date2011-12-31
Total amount of commissions paid to insurance brokerUSD $49,776
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $331,840
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
VISION COVERAGE VISIONPLUS OF AMERICA (National Association of Insurance Commissioners NAIC id number: 74322 )
Policy contract number10042
Policy instance 2
Insurance contract or identification number10042
Number of Individuals Covered480
Insurance policy start date2011-01-01
Insurance policy end date2011-12-31
Total amount of commissions paid to insurance brokerUSD $6,534
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $94,696
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93440 )
Policy contract number10042
Policy instance 1
Insurance contract or identification number10042
Number of Individuals Covered398
Insurance policy start date2010-01-01
Insurance policy end date2010-12-31
Total amount of commissions paid to insurance brokerUSD $30,150
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?Yes
Were dividends or retroactive rate refunds paid as a credit?No
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
VISION VISIONPLUS OF AMERICA (National Association of Insurance Commissioners NAIC id number: )
Policy contract number10042
Policy instance 2
Insurance contract or identification number10042
Number of Individuals Covered398
Insurance policy start date2008-01-01
Insurance policy end date2008-12-31
Total amount of commissions paid to insurance brokerUSD $5,459
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No

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