FIRST UROLOGY PSC has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan FIRST UROLOGY, PSC WELFARE PLAN
| 2022: FIRST UROLOGY, PSC WELFARE PLAN 2022 form 5500 responses |
|---|
| 2022-07-01 | Type of plan entity | Single employer plan |
| 2022-07-01 | Submission has been amended | No |
| 2022-07-01 | This submission is the final filing | No |
| 2022-07-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2022-07-01 | Plan is a collectively bargained plan | No |
| 2022-07-01 | Plan funding arrangement – Insurance | Yes |
| 2022-07-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2022-07-01 | Plan benefit arrangement – Insurance | Yes |
| 2021: FIRST UROLOGY, PSC WELFARE PLAN 2021 form 5500 responses |
|---|
| 2021-07-01 | Type of plan entity | Single employer plan |
| 2021-07-01 | Submission has been amended | No |
| 2021-07-01 | This submission is the final filing | No |
| 2021-07-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2021-07-01 | Plan is a collectively bargained plan | No |
| 2021-07-01 | Plan funding arrangement – Insurance | Yes |
| 2021-07-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2021-07-01 | Plan benefit arrangement – Insurance | Yes |
| 2020: FIRST UROLOGY, PSC WELFARE PLAN 2020 form 5500 responses |
|---|
| 2020-07-01 | Type of plan entity | Single employer plan |
| 2020-07-01 | Submission has been amended | No |
| 2020-07-01 | This submission is the final filing | No |
| 2020-07-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2020-07-01 | Plan is a collectively bargained plan | No |
| 2020-07-01 | Plan funding arrangement – Insurance | Yes |
| 2020-07-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2020-07-01 | Plan benefit arrangement – Insurance | Yes |
| 2019: FIRST UROLOGY, PSC WELFARE PLAN 2019 form 5500 responses |
|---|
| 2019-07-01 | Type of plan entity | Single employer plan |
| 2019-07-01 | Submission has been amended | No |
| 2019-07-01 | This submission is the final filing | No |
| 2019-07-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2019-07-01 | Plan is a collectively bargained plan | No |
| 2019-07-01 | Plan funding arrangement – Insurance | Yes |
| 2019-07-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2019-07-01 | Plan benefit arrangement – Insurance | Yes |
| 2018: FIRST UROLOGY, PSC WELFARE PLAN 2018 form 5500 responses |
|---|
| 2018-07-01 | Type of plan entity | Single employer plan |
| 2018-07-01 | Submission has been amended | No |
| 2018-07-01 | This submission is the final filing | No |
| 2018-07-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2018-07-01 | Plan is a collectively bargained plan | No |
| 2018-07-01 | Plan funding arrangement – Insurance | Yes |
| 2018-07-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2018-07-01 | Plan benefit arrangement – Insurance | Yes |
| 2017: FIRST UROLOGY, PSC WELFARE PLAN 2017 form 5500 responses |
|---|
| 2017-07-01 | Type of plan entity | Single employer plan |
| 2017-07-01 | Submission has been amended | No |
| 2017-07-01 | This submission is the final filing | No |
| 2017-07-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2017-07-01 | Plan is a collectively bargained plan | No |
| 2017-07-01 | Plan funding arrangement – Insurance | Yes |
| 2017-07-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2017-07-01 | Plan benefit arrangement – Insurance | Yes |
| 2016: FIRST UROLOGY, PSC WELFARE PLAN 2016 form 5500 responses |
|---|
| 2016-07-01 | Type of plan entity | Single employer plan |
| 2016-07-01 | Submission has been amended | No |
| 2016-07-01 | This submission is the final filing | No |
| 2016-07-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2016-07-01 | Plan is a collectively bargained plan | No |
| 2016-07-01 | Plan funding arrangement – Insurance | Yes |
| 2016-07-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2016-07-01 | Plan benefit arrangement – Insurance | Yes |
| 2015: FIRST UROLOGY, PSC WELFARE PLAN 2015 form 5500 responses |
|---|
| 2015-07-01 | Type of plan entity | Single employer plan |
| 2015-07-01 | Submission has been amended | No |
| 2015-07-01 | This submission is the final filing | No |
| 2015-07-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2015-07-01 | Plan is a collectively bargained plan | No |
| 2015-07-01 | Plan funding arrangement – Insurance | Yes |
| 2015-07-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2015-07-01 | Plan benefit arrangement – Insurance | Yes |
| 2014: FIRST UROLOGY, PSC WELFARE PLAN 2014 form 5500 responses |
|---|
| 2014-07-01 | Type of plan entity | Single employer plan |
| 2014-07-01 | Submission has been amended | No |
| 2014-07-01 | This submission is the final filing | No |
| 2014-07-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2014-07-01 | Plan is a collectively bargained plan | No |
| 2014-07-01 | Plan funding arrangement – Insurance | Yes |
| 2014-07-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2014-07-01 | Plan benefit arrangement – Insurance | Yes |
| 2013: FIRST UROLOGY, PSC WELFARE PLAN 2013 form 5500 responses |
|---|
| 2013-07-01 | Type of plan entity | Single employer plan |
| 2013-07-01 | Submission has been amended | No |
| 2013-07-01 | This submission is the final filing | No |
| 2013-07-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2013-07-01 | Plan is a collectively bargained plan | No |
| 2013-07-01 | Plan funding arrangement – Insurance | Yes |
| 2013-07-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2013-07-01 | Plan benefit arrangement – Insurance | Yes |
| 2012: FIRST UROLOGY, PSC WELFARE PLAN 2012 form 5500 responses |
|---|
| 2012-07-01 | Type of plan entity | Single employer plan |
| 2012-07-01 | Submission has been amended | No |
| 2012-07-01 | This submission is the final filing | No |
| 2012-07-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2012-07-01 | Plan is a collectively bargained plan | No |
| 2012-07-01 | Plan funding arrangement – Insurance | Yes |
| 2012-07-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2012-07-01 | Plan benefit arrangement – Insurance | Yes |
| 2011: FIRST UROLOGY, PSC WELFARE PLAN 2011 form 5500 responses |
|---|
| 2011-07-01 | Type of plan entity | Single employer plan |
| 2011-07-01 | Submission has been amended | No |
| 2011-07-01 | This submission is the final filing | No |
| 2011-07-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2011-07-01 | Plan is a collectively bargained plan | No |
| 2011-07-01 | Plan funding arrangement – Insurance | Yes |
| 2011-07-01 | Plan benefit arrangement – Insurance | Yes |
| 2009: FIRST UROLOGY, PSC WELFARE PLAN 2009 form 5500 responses |
|---|
| 2009-07-01 | Type of plan entity | Single employer plan |
| 2009-07-01 | Submission has been amended | No |
| 2009-07-01 | This submission is the final filing | No |
| 2009-07-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2009-07-01 | Plan is a collectively bargained plan | No |
| 2009-07-01 | Plan funding arrangement – Insurance | Yes |
| 2009-07-01 | Plan benefit arrangement – Insurance | Yes |
| 2008: FIRST UROLOGY, PSC WELFARE PLAN 2008 form 5500 responses |
|---|
| 2008-07-01 | Type of plan entity | Single employer plan |
| 2008-07-01 | Submission has been amended | No |
| 2008-07-01 | This submission is the final filing | No |
| 2008-07-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2008-07-01 | Plan is a collectively bargained plan | No |
| 2008-07-01 | Plan funding arrangement – Insurance | Yes |
| 2008-07-01 | Plan benefit arrangement – Insurance | Yes |
| COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 ) |
| Policy contract number | E7964802 |
| Policy instance | 5 |
| Insurance contract or identification number | E7964802 | | Number of Individuals Covered | 2 | | Insurance policy start date | 2021-09-01 | | Insurance policy end date | 2022-08-31 | | Total amount of commissions paid to insurance broker | USD $17 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $347 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4 | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 64548 ) |
| Policy contract number | LK964217 |
| Policy instance | 10 |
| Insurance contract or identification number | LK964217 | | Number of Individuals Covered | 237 | | Insurance policy start date | 2022-05-01 | | Insurance policy end date | 2023-04-30 | | Total amount of commissions paid to insurance broker | USD $32,240 | | Total amount of fees paid to insurance company | USD $0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $214,936 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $32,240 | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 64548 ) |
| Policy contract number | OK967684 |
| Policy instance | 1 |
| Insurance contract or identification number | OK967684 | | Number of Individuals Covered | 314 | | Insurance policy start date | 2022-05-01 | | Insurance policy end date | 2023-04-30 | | Total amount of commissions paid to insurance broker | USD $1,412 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | BASIC AND VOLUNTARY AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $7,603 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,412 | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 64548 ) |
| Policy contract number | AI961517 |
| Policy instance | 2 |
| Insurance contract or identification number | AI961517 | | Number of Individuals Covered | 80 | | Insurance policy start date | 2022-05-01 | | Insurance policy end date | 2023-04-30 | | Total amount of commissions paid to insurance broker | USD $2,657 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | ACCIDENTAL INJURY | | Welfare Benefit Premiums Paid to Carrier | USD $13,294 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,657 | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 64548 ) |
| Policy contract number | VDT961657 |
| Policy instance | 3 |
| Insurance contract or identification number | VDT961657 | | Number of Individuals Covered | 142 | | Insurance policy start date | 2022-05-01 | | Insurance policy end date | 2023-04-30 | | Total amount of commissions paid to insurance broker | USD $11,248 | | Total amount of fees paid to insurance company | USD $0 | | Temporary Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | VOLUNTARY SHORT TERM DISABILITY | | Welfare Benefit Premiums Paid to Carrier | USD $56,239 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $11,248 | | Insurance broker organization code? | 3 |
|
| HUMANA HEALTH PLAN, INC. (National Association of Insurance Commissioners NAIC id number: 95885 ) |
| Policy contract number | 846239 |
| Policy instance | 4 |
| Insurance contract or identification number | 846239 | | Number of Individuals Covered | 121 | | Insurance policy start date | 2022-05-01 | | Insurance policy end date | 2023-04-30 | | Total amount of commissions paid to insurance broker | USD $60,580 | | Total amount of fees paid to insurance company | USD $2,001 | | Health Insurance Welfare Benefit | Yes | | Other welfare benefits provided | EMPLOYEE ASSISTANCE PROGRAM | | Welfare Benefit Premiums Paid to Carrier | USD $1,770,707 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $46,376 | | Amount paid for insurance broker fees | 1939 | | Additional information about fees paid to insurance broker | BONUS PAID | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 64548 ) |
| Policy contract number | FLX966138 |
| Policy instance | 6 |
| Insurance contract or identification number | FLX966138 | | Number of Individuals Covered | 250 | | Insurance policy start date | 2022-05-01 | | Insurance policy end date | 2023-04-30 | | Total amount of commissions paid to insurance broker | USD $8,327 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | VOLUNTARY TERM LIFE | | Welfare Benefit Premiums Paid to Carrier | USD $43,514 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,327 | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 64548 ) |
| Policy contract number | HC960796 |
| Policy instance | 7 |
| Insurance contract or identification number | HC960796 | | Number of Individuals Covered | 1 | | Insurance policy start date | 2022-05-01 | | Insurance policy end date | 2023-04-30 | | Total amount of commissions paid to insurance broker | USD $30 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | VOLUNTARY HOSPITAL CARE | | Welfare Benefit Premiums Paid to Carrier | USD $150 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $30 | | Insurance broker organization code? | 3 |
|
| ANTHEM INSURANCE COMPANIES, INC (National Association of Insurance Commissioners NAIC id number: 28207 ) |
| Policy contract number | W13121 |
| Policy instance | 8 |
| Insurance contract or identification number | W13121 | | Number of Individuals Covered | 350 | | Insurance policy start date | 2022-05-01 | | Insurance policy end date | 2023-04-30 | | Total amount of commissions paid to insurance broker | USD $8,559 | | Total amount of fees paid to insurance company | USD $6,138 | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $146,550 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,484 | | Amount paid for insurance broker fees | 6138 | | Additional information about fees paid to insurance broker | BONUS PAID | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 64548 ) |
| Policy contract number | CI961443 |
| Policy instance | 9 |
| Insurance contract or identification number | CI961443 | | Number of Individuals Covered | 120 | | Insurance policy start date | 2022-05-01 | | Insurance policy end date | 2023-04-30 | | Total amount of commissions paid to insurance broker | USD $4,160 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | VOLUNTARY CRITICAL ILLNESS | | Welfare Benefit Premiums Paid to Carrier | USD $20,799 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,160 | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 64548 ) |
| Policy contract number | LK964217 |
| Policy instance | 3 |
| Insurance contract or identification number | LK964217 | | Number of Individuals Covered | 323 | | Insurance policy start date | 2021-05-01 | | Insurance policy end date | 2022-04-30 | | Total amount of commissions paid to insurance broker | USD $35,098 | | Total amount of fees paid to insurance company | USD $6,106 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $233,984 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $35,098 | | Amount paid for insurance broker fees | 6106 | | Additional information about fees paid to insurance broker | OVERRIDE FEE | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 64548 ) |
| Policy contract number | FLX966138 |
| Policy instance | 1 |
| Insurance contract or identification number | FLX966138 | | Number of Individuals Covered | 454 | | Insurance policy start date | 2021-05-01 | | Insurance policy end date | 2022-04-30 | | Total amount of commissions paid to insurance broker | USD $8,415 | | Total amount of fees paid to insurance company | USD $1,374 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | VOLUNTARY TERM LIFE | | Welfare Benefit Premiums Paid to Carrier | USD $44,314 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,415 | | Amount paid for insurance broker fees | 1374 | | Additional information about fees paid to insurance broker | OVERRIDE FEE | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 64548 ) |
| Policy contract number | HC960796 |
| Policy instance | 2 |
| Insurance contract or identification number | HC960796 | | Number of Individuals Covered | 1 | | Insurance policy start date | 2021-05-01 | | Insurance policy end date | 2022-04-30 | | Total amount of commissions paid to insurance broker | USD $125 | | Total amount of fees paid to insurance company | USD $60 | | Other welfare benefits provided | VOLUNTARY HOSPITAL CARE | | Welfare Benefit Premiums Paid to Carrier | USD $626 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $125 | | Amount paid for insurance broker fees | 60 | | Additional information about fees paid to insurance broker | OVERRIDE FEE | | Insurance broker organization code? | 3 |
|
| HUMANA HEALTH PLAN, INC. (National Association of Insurance Commissioners NAIC id number: 95885 ) |
| Policy contract number | 846239 |
| Policy instance | 4 |
| Insurance contract or identification number | 846239 | | Number of Individuals Covered | 181 | | Insurance policy start date | 2021-05-01 | | Insurance policy end date | 2022-04-30 | | Total amount of commissions paid to insurance broker | USD $55,551 | | Total amount of fees paid to insurance company | USD $7,072 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,595,486 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $41,663 | | Amount paid for insurance broker fees | 7072 | | Additional information about fees paid to insurance broker | BONUS COMPENSATION | | Insurance broker organization code? | 3 |
|
| COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 ) |
| Policy contract number | E7964802 |
| Policy instance | 5 |
| Insurance contract or identification number | E7964802 | | Number of Individuals Covered | 2 | | Insurance policy start date | 2020-09-01 | | Insurance policy end date | 2021-08-31 | | Total amount of commissions paid to insurance broker | USD $39 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $978 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $10 | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 64548 ) |
| Policy contract number | OK967684 |
| Policy instance | 6 |
| Insurance contract or identification number | OK967684 | | Number of Individuals Covered | 451 | | Insurance policy start date | 2021-05-01 | | Insurance policy end date | 2022-04-30 | | Total amount of commissions paid to insurance broker | USD $1,441 | | Total amount of fees paid to insurance company | USD $177 | | Other welfare benefits provided | BASIC AND VOLUNTARY AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $7,613 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,441 | | Amount paid for insurance broker fees | 177 | | Additional information about fees paid to insurance broker | OVERRIDE FEE | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 64548 ) |
| Policy contract number | VDT961657 |
| Policy instance | 7 |
| Insurance contract or identification number | VDT961657 | | Number of Individuals Covered | 145 | | Insurance policy start date | 2021-05-01 | | Insurance policy end date | 2022-04-30 | | Total amount of commissions paid to insurance broker | USD $11,455 | | Total amount of fees paid to insurance company | USD $1,448 | | Other welfare benefits provided | VOLUNTARY SHORT TERM DISABILITY | | Welfare Benefit Premiums Paid to Carrier | USD $57,274 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $11,455 | | Amount paid for insurance broker fees | 1448 | | Additional information about fees paid to insurance broker | OVERRIDE FEE | | Insurance broker organization code? | 3 |
|
| ANTHEM INSURANCE COMPANIES, INC (National Association of Insurance Commissioners NAIC id number: 28207 ) |
| Policy contract number | W13121 |
| Policy instance | 8 |
| Insurance contract or identification number | W13121 | | Number of Individuals Covered | 325 | | Insurance policy start date | 2021-05-01 | | Insurance policy end date | 2022-04-30 | | Total amount of commissions paid to insurance broker | USD $12,911 | | Total amount of fees paid to insurance company | USD $5,496 | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $123,770 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,568 | | Amount paid for insurance broker fees | 2499 | | Additional information about fees paid to insurance broker | BONUS COMPENSATION | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 64548 ) |
| Policy contract number | CI961443 |
| Policy instance | 9 |
| Insurance contract or identification number | CI961443 | | Number of Individuals Covered | 60 | | Insurance policy start date | 2021-05-01 | | Insurance policy end date | 2022-04-30 | | Total amount of commissions paid to insurance broker | USD $4,461 | | Total amount of fees paid to insurance company | USD $1,034 | | Other welfare benefits provided | VOLUNTARY CRITICAL ILLNESS | | Welfare Benefit Premiums Paid to Carrier | USD $22,306 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,461 | | Amount paid for insurance broker fees | 1034 | | Additional information about fees paid to insurance broker | OVERRIDE FEE | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 64548 ) |
| Policy contract number | AI961517 |
| Policy instance | 10 |
| Insurance contract or identification number | AI961517 | | Number of Individuals Covered | 93 | | Insurance policy start date | 2021-05-01 | | Insurance policy end date | 2022-04-30 | | Total amount of commissions paid to insurance broker | USD $2,927 | | Total amount of fees paid to insurance company | USD $626 | | Other welfare benefits provided | ACCIDENTAL INJURY | | Welfare Benefit Premiums Paid to Carrier | USD $14,626 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,927 | | Amount paid for insurance broker fees | 626 | | Additional information about fees paid to insurance broker | OVERRIDE FEE | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 64548 ) |
| Policy contract number | AI961517 |
| Policy instance | 1 |
| Insurance contract or identification number | AI961517 | | Number of Individuals Covered | 109 | | Insurance policy start date | 2020-05-01 | | Insurance policy end date | 2021-04-30 | | Total amount of commissions paid to insurance broker | USD $2,391 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | ACCIDENTAL INJURY | | Welfare Benefit Premiums Paid to Carrier | USD $11,955 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,391 | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 64548 ) |
| Policy contract number | OK967684 |
| Policy instance | 2 |
| Insurance contract or identification number | OK967684 | | Number of Individuals Covered | 377 | | Insurance policy start date | 2020-05-01 | | Insurance policy end date | 2021-04-30 | | Total amount of commissions paid to insurance broker | USD $1,288 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | BASIC AND VOLUNTARY AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $5,953 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,288 | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 64548 ) |
| Policy contract number | HC960796 |
| Policy instance | 3 |
| Insurance contract or identification number | HC960796 | | Number of Individuals Covered | 4 | | Insurance policy start date | 2020-06-01 | | Insurance policy end date | 2021-04-30 | | Total amount of commissions paid to insurance broker | USD $203 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | VOLUNTARY HOSPITAL CARE | | Welfare Benefit Premiums Paid to Carrier | USD $1,015 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $203 | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 64548 ) |
| Policy contract number | LK964217 |
| Policy instance | 4 |
| Insurance contract or identification number | LK964217 | | Number of Individuals Covered | 298 | | Insurance policy start date | 2020-05-01 | | Insurance policy end date | 2021-04-30 | | Total amount of commissions paid to insurance broker | USD $36,434 | | Total amount of fees paid to insurance company | USD $0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $210,060 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $36,434 | | Insurance broker organization code? | 3 |
|
| COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 ) |
| Policy contract number | E7964802 |
| Policy instance | 5 |
| Insurance contract or identification number | E7964802 | | Number of Individuals Covered | 2 | | Insurance policy start date | 2019-09-01 | | Insurance policy end date | 2020-08-31 | | Total amount of commissions paid to insurance broker | USD $36 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,033 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $9 | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 64548 ) |
| Policy contract number | VDT961657 |
| Policy instance | 6 |
| Insurance contract or identification number | VDT961657 | | Number of Individuals Covered | 119 | | Insurance policy start date | 2020-05-01 | | Insurance policy end date | 2021-04-30 | | Total amount of commissions paid to insurance broker | USD $11,012 | | Total amount of fees paid to insurance company | USD $0 | | Temporary Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | VOLUNTARY SHORT TERM DISABILITY | | Welfare Benefit Premiums Paid to Carrier | USD $47,557 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $11,012 | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 64548 ) |
| Policy contract number | CI961443 |
| Policy instance | 8 |
| Insurance contract or identification number | CI961443 | | Number of Individuals Covered | 104 | | Insurance policy start date | 2020-05-01 | | Insurance policy end date | 2021-04-30 | | Total amount of commissions paid to insurance broker | USD $4,118 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | VOLUNTARY CRITICAL ILLNESS | | Welfare Benefit Premiums Paid to Carrier | USD $20,589 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,118 | | Insurance broker organization code? | 3 |
|
| ANTHEM INSURANCE COMPANIES, INC (National Association of Insurance Commissioners NAIC id number: 28207 ) |
| Policy contract number | W13121 |
| Policy instance | 9 |
| Insurance contract or identification number | W13121 | | Number of Individuals Covered | 345 | | Insurance policy start date | 2020-05-01 | | Insurance policy end date | 2021-04-30 | | Total amount of commissions paid to insurance broker | USD $33,596 | | Total amount of fees paid to insurance company | USD $4,528 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,743,434 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $11,919 | | Amount paid for insurance broker fees | 4528 | | Additional information about fees paid to insurance broker | BONUS COMPENSATION | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 64548 ) |
| Policy contract number | FLX966138 |
| Policy instance | 7 |
| Insurance contract or identification number | FLX966138 | | Number of Individuals Covered | 396 | | Insurance policy start date | 2020-05-01 | | Insurance policy end date | 2021-04-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | VOLUNTARY TERM LIFE | | Welfare Benefit Premiums Paid to Carrier | USD $45,676 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 64548 ) |
| Policy contract number | OK967684 |
| Policy instance | 1 |
| Insurance contract or identification number | OK967684 | | Number of Individuals Covered | 480 | | Insurance policy start date | 2019-05-01 | | Insurance policy end date | 2020-04-30 | | Total amount of commissions paid to insurance broker | USD $1,009 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | BASIC AND VOLUNTARY AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $5,812 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,009 | | Insurance broker organization code? | 3 |
|
| ANTHEM INSURANCE COMPANIES, INC (National Association of Insurance Commissioners NAIC id number: 28207 ) |
| Policy contract number | 00250191 |
| Policy instance | 2 |
| Insurance contract or identification number | 00250191 | | Number of Individuals Covered | 304 | | Insurance policy start date | 2019-05-01 | | Insurance policy end date | 2020-04-30 | | Total amount of commissions paid to insurance broker | USD $218 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $26,585 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $126 | | Insurance broker organization code? | 3 |
|
| COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 ) |
| Policy contract number | E7964802 |
| Policy instance | 3 |
| Insurance contract or identification number | E7964802 | | Number of Individuals Covered | 3 | | Insurance policy start date | 2018-09-01 | | Insurance policy end date | 2019-08-31 | | Total amount of commissions paid to insurance broker | USD $39 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $978 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $10 | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 64548 ) |
| Policy contract number | LK964217 |
| Policy instance | 4 |
| Insurance contract or identification number | LK964217 | | Number of Individuals Covered | 282 | | Insurance policy start date | 2019-05-01 | | Insurance policy end date | 2020-04-30 | | Total amount of commissions paid to insurance broker | USD $27,328 | | Total amount of fees paid to insurance company | USD $0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $198,603 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $27,328 | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 64548 ) |
| Policy contract number | FLX966138 |
| Policy instance | 6 |
| Insurance contract or identification number | FLX966138 | | Number of Individuals Covered | 542 | | Insurance policy start date | 2019-05-01 | | Insurance policy end date | 2020-04-30 | | Total amount of commissions paid to insurance broker | USD $8,019 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | VOLUNTARY LIFE | | Welfare Benefit Premiums Paid to Carrier | USD $45,293 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,019 | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 64548 ) |
| Policy contract number | VDT961657 |
| Policy instance | 5 |
| Insurance contract or identification number | VDT961657 | | Number of Individuals Covered | 121 | | Insurance policy start date | 2019-05-01 | | Insurance policy end date | 2020-04-30 | | Total amount of commissions paid to insurance broker | USD $8,992 | | Total amount of fees paid to insurance company | USD $0 | | Temporary Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | VOLUNTARY SHORT TERM DISABILITY | | Welfare Benefit Premiums Paid to Carrier | USD $48,712 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,992 | | Insurance broker organization code? | 3 |
|
| ANTHEM INSURANCE COMPANIES, INC (National Association of Insurance Commissioners NAIC id number: 28207 ) |
| Policy contract number | 00250191 |
| Policy instance | 7 |
| Insurance contract or identification number | 00250191 | | Number of Individuals Covered | 311 | | Insurance policy start date | 2019-05-01 | | Insurance policy end date | 2020-04-30 | | Total amount of commissions paid to insurance broker | USD $14,334 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,743,405 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,282 | | Insurance broker organization code? | 3 |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 928276 |
| Policy instance | 8 |
| Insurance contract or identification number | 928276 | | Number of Individuals Covered | 26 | | Insurance policy start date | 2019-05-01 | | Insurance policy end date | 2020-04-30 | | Total amount of commissions paid to insurance broker | USD $3,940 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | EE ACCIDENT & CANCER; EE-SP-CHD CRITICAL ILLNESS | | Welfare Benefit Premiums Paid to Carrier | USD $19,702 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,940 | | Insurance broker organization code? | 3 |
|
| ANTHEM INSURANCE COMPANIES, INC (National Association of Insurance Commissioners NAIC id number: 28207 ) |
| Policy contract number | 941804 |
| Policy instance | 9 |
| Insurance contract or identification number | 941804 | | Number of Individuals Covered | 177 | | Insurance policy start date | 2019-05-01 | | Insurance policy end date | 2020-04-30 | | Total amount of commissions paid to insurance broker | USD $9,802 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $113,374 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $9,802 | | Insurance broker organization code? | 3 |
|
| HUMANA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 73288 ) |
| Policy contract number | 767501 |
| Policy instance | 5 |
| Insurance contract or identification number | 767501 | | Number of Individuals Covered | 180 | | Insurance policy start date | 2018-05-01 | | Insurance policy end date | 2019-04-30 | | Total amount of commissions paid to insurance broker | USD $3,562 | | Total amount of fees paid to insurance company | USD $1,402 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $104,428 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,562 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 1402 | | Additional information about fees paid to insurance broker | BONUS PAID |
|
| ANTHEM INSURANCE COMPANIES, INC (National Association of Insurance Commissioners NAIC id number: 28207 ) |
| Policy contract number | 00250191 |
| Policy instance | 6 |
| Insurance contract or identification number | 00250191 | | Number of Individuals Covered | 308 | | Insurance policy start date | 2018-05-01 | | Insurance policy end date | 2019-04-30 | | Total amount of commissions paid to insurance broker | USD $2,904 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $23,796 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,904 | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 64548 ) |
| Policy contract number | FLX966138 |
| Policy instance | 7 |
| Insurance contract or identification number | FLX966138 | | Number of Individuals Covered | 547 | | Insurance policy start date | 2018-05-01 | | Insurance policy end date | 2019-04-30 | | Total amount of commissions paid to insurance broker | USD $8,785 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | VOLUNTARY LIFE | | Welfare Benefit Premiums Paid to Carrier | USD $45,793 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,785 | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 64548 ) |
| Policy contract number | LK964217 |
| Policy instance | 8 |
| Insurance contract or identification number | LK964217 | | Number of Individuals Covered | 280 | | Insurance policy start date | 2018-05-01 | | Insurance policy end date | 2019-04-30 | | Total amount of commissions paid to insurance broker | USD $29,468 | | Total amount of fees paid to insurance company | USD $0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $196,660 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $29,468 | | Insurance broker organization code? | 3 |
|
| ANTHEM INSURANCE COMPANIES, INC (National Association of Insurance Commissioners NAIC id number: 28207 ) |
| Policy contract number | 00250191 |
| Policy instance | 9 |
| Insurance contract or identification number | 00250191 | | Number of Individuals Covered | 317 | | Insurance policy start date | 2018-05-01 | | Insurance policy end date | 2019-04-30 | | Total amount of commissions paid to insurance broker | USD $4,759 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,540,763 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,759 | | Insurance broker organization code? | 3 |
|
| UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 ) |
| Policy contract number | 4054003 |
| Policy instance | 4 |
| Insurance contract or identification number | 4054003 | | Number of Individuals Covered | 80 | | Insurance policy start date | 2018-05-01 | | Insurance policy end date | 2019-04-30 | | Total amount of commissions paid to insurance broker | USD $4,401 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | ACCIDENT, CANCER AND CRITICAL ILLNESS | | Welfare Benefit Premiums Paid to Carrier | USD $22,141 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,401 | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 64548 ) |
| Policy contract number | OK967684 |
| Policy instance | 3 |
| Insurance contract or identification number | OK967684 | | Number of Individuals Covered | 482 | | Insurance policy start date | 2018-05-01 | | Insurance policy end date | 2019-04-30 | | Total amount of commissions paid to insurance broker | USD $1,075 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | BASIC AND VOLUNTARY AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $5,715 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,075 | | Insurance broker organization code? | 3 |
|
| COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 ) |
| Policy contract number | E7964802 |
| Policy instance | 2 |
| Insurance contract or identification number | E7964802 | | Number of Individuals Covered | 3 | | Insurance policy start date | 2017-09-01 | | Insurance policy end date | 2018-08-31 | | Total amount of commissions paid to insurance broker | USD $42 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $978 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $11 | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 64548 ) |
| Policy contract number | VDT961657 |
| Policy instance | 1 |
| Insurance contract or identification number | VDT961657 | | Number of Individuals Covered | 121 | | Insurance policy start date | 2018-05-01 | | Insurance policy end date | 2019-04-30 | | Total amount of commissions paid to insurance broker | USD $10,110 | | Total amount of fees paid to insurance company | USD $0 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $50,548 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $10,110 | | Insurance broker organization code? | 3 |
|
| ANTHEM INSURANCE COMPANIES, INC (National Association of Insurance Commissioners NAIC id number: 28207 ) |
| Policy contract number | 00250191 |
| Policy instance | 1 |
| Insurance contract or identification number | 00250191 | | Number of Individuals Covered | 296 | | Insurance policy start date | 2017-05-01 | | Insurance policy end date | 2018-04-30 | | Total amount of commissions paid to insurance broker | USD $24,198 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,277,923 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 64548 ) |
| Policy contract number | VDT961657 |
| Policy instance | 3 |
| Insurance contract or identification number | VDT961657 | | Number of Individuals Covered | 125 | | Insurance policy start date | 2017-05-01 | | Insurance policy end date | 2018-04-30 | | Total amount of commissions paid to insurance broker | USD $10,704 | | Total amount of fees paid to insurance company | USD $0 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $53,519 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 64548 ) |
| Policy contract number | LK964217 |
| Policy instance | 2 |
| Insurance contract or identification number | LK964217 | | Number of Individuals Covered | 279 | | Insurance policy start date | 2017-05-01 | | Insurance policy end date | 2018-04-30 | | Total amount of commissions paid to insurance broker | USD $27,250 | | Total amount of fees paid to insurance company | USD $0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $181,668 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 ) |
| Policy contract number | E7964802 |
| Policy instance | 4 |
| Insurance contract or identification number | E7964802 | | Number of Individuals Covered | 3 | | Insurance policy start date | 2016-09-01 | | Insurance policy end date | 2017-08-31 | | Total amount of commissions paid to insurance broker | USD $42 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $978 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HUMANA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 73288 ) |
| Policy contract number | 767501 |
| Policy instance | 5 |
| Insurance contract or identification number | 767501 | | Number of Individuals Covered | 179 | | Insurance policy start date | 2017-05-01 | | Insurance policy end date | 2018-04-30 | | Total amount of commissions paid to insurance broker | USD $3,389 | | Total amount of fees paid to insurance company | USD $2,757 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $91,483 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| ANTHEM INSURANCE COMPANIES, INC (National Association of Insurance Commissioners NAIC id number: 28207 ) |
| Policy contract number | 00250191 |
| Policy instance | 6 |
| Insurance contract or identification number | 00250191 | | Number of Individuals Covered | 301 | | Insurance policy start date | 2017-05-01 | | Insurance policy end date | 2018-04-30 | | Total amount of commissions paid to insurance broker | USD $444 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $23,174 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 64548 ) |
| Policy contract number | FLX966138 |
| Policy instance | 7 |
| Insurance contract or identification number | FLX966138 | | Number of Individuals Covered | 274 | | Insurance policy start date | 2017-05-01 | | Insurance policy end date | 2018-04-30 | | Total amount of commissions paid to insurance broker | USD $7,641 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | VOLUNTARY LIFE | | Welfare Benefit Premiums Paid to Carrier | USD $39,975 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 64548 ) |
| Policy contract number | OK967684 |
| Policy instance | 8 |
| Insurance contract or identification number | OK967684 | | Number of Individuals Covered | 277 | | Insurance policy start date | 2017-05-01 | | Insurance policy end date | 2018-04-30 | | Total amount of commissions paid to insurance broker | USD $967 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | BASIC AND VOLUNTARY AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $5,178 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 64548 ) |
| Policy contract number | VDT961657 |
| Policy instance | 6 |
| Insurance contract or identification number | VDT961657 | | Number of Individuals Covered | 121 | | Insurance policy start date | 2015-07-02 | | Insurance policy end date | 2016-04-30 | | Total amount of commissions paid to insurance broker | USD $10,092 | | Total amount of fees paid to insurance company | USD $0 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $50,461 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $10,092 | | Insurance broker organization code? | 3 | | Insurance broker name | WILLIAM PATRICK SHANNON |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 64548 ) |
| Policy contract number | OK967684 |
| Policy instance | 5 |
| Insurance contract or identification number | OK967684 | | Number of Individuals Covered | 208 | | Insurance policy start date | 2014-09-01 | | Insurance policy end date | 2015-07-01 | | Total amount of commissions paid to insurance broker | USD $523 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | BASIC AND VOLUNTARY AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $2,779 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $523 | | Insurance broker organization code? | 3 | | Insurance broker name | WILLIAM PATRICK SHANNON |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 64548 ) |
| Policy contract number | LK964217 |
| Policy instance | 4 |
| Insurance contract or identification number | LK964217 | | Number of Individuals Covered | 236 | | Insurance policy start date | 2015-07-02 | | Insurance policy end date | 2016-04-30 | | Total amount of commissions paid to insurance broker | USD $19,437 | | Total amount of fees paid to insurance company | USD $0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $129,581 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $19,437 | | Insurance broker organization code? | 3 | | Insurance broker name | WILLIAM PATRICK SHANNON |
|
| COMPBENEFITS (National Association of Insurance Commissioners NAIC id number: 60984 ) |
| Policy contract number | 584370 |
| Policy instance | 3 |
| Insurance contract or identification number | 584370 | | Number of Individuals Covered | 122 | | Insurance policy start date | 2015-05-01 | | Insurance policy end date | 2016-04-30 | | Total amount of commissions paid to insurance broker | USD $1,625 | | Total amount of fees paid to insurance company | USD $2,630 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $17,770 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,618 | | Amount paid for insurance broker fees | 2630 | | Additional information about fees paid to insurance broker | BONUS PAID | | Insurance broker organization code? | 3 | | Insurance broker name | USI INSURANCE SERVICES, LLC |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 64548 ) |
| Policy contract number | LK964217 |
| Policy instance | 2 |
| Insurance contract or identification number | LK964217 | | Number of Individuals Covered | 208 | | Insurance policy start date | 2014-09-01 | | Insurance policy end date | 2015-07-01 | | Total amount of commissions paid to insurance broker | USD $11,528 | | Total amount of fees paid to insurance company | USD $0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $76,861 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $11,528 | | Insurance broker organization code? | 3 | | Insurance broker name | WILLIAM PATRICK SHANNON |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 64548 ) |
| Policy contract number | OK967684 |
| Policy instance | 1 |
| Insurance contract or identification number | OK967684 | | Number of Individuals Covered | 236 | | Insurance policy start date | 2015-07-02 | | Insurance policy end date | 2016-04-30 | | Total amount of commissions paid to insurance broker | USD $968 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | BASIC AND VOLUNTARY AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $5,195 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $968 | | Insurance broker organization code? | 3 | | Insurance broker name | WILLIAM PATRICK SHANNON |
|
| UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 ) |
| Policy contract number | 5454555 |
| Policy instance | 7 |
| Insurance contract or identification number | 5454555 | | Number of Individuals Covered | 142 | | Insurance policy start date | 2014-09-01 | | Insurance policy end date | 2015-08-31 | | Total amount of commissions paid to insurance broker | USD $4,933 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $98,670 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,933 | | Insurance broker organization code? | 3 | | Insurance broker name | JARBOE SHANNON GROUP, LLC |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 64548 ) |
| Policy contract number | VDT961657 |
| Policy instance | 8 |
| Insurance contract or identification number | VDT961657 | | Number of Individuals Covered | 95 | | Insurance policy start date | 2014-09-01 | | Insurance policy end date | 2015-07-01 | | Total amount of commissions paid to insurance broker | USD $5,493 | | Total amount of fees paid to insurance company | USD $0 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $27,467 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,493 | | Insurance broker organization code? | 3 | | Insurance broker name | WILLIAM PATRICK SHANNON |
|
| COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 ) |
| Policy contract number | E7964802 |
| Policy instance | 9 |
| Insurance contract or identification number | E7964802 | | Number of Individuals Covered | 2 | | Insurance policy start date | 2014-09-01 | | Insurance policy end date | 2015-08-31 | | Total amount of commissions paid to insurance broker | USD $36 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $978 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $9 | | Insurance broker organization code? | 3 | | Insurance broker name | LISA GRAVES |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 64548 ) |
| Policy contract number | FLX966138 |
| Policy instance | 10 |
| Insurance contract or identification number | FLX966138 | | Number of Individuals Covered | 236 | | Insurance policy start date | 2015-07-02 | | Insurance policy end date | 2016-04-30 | | Total amount of commissions paid to insurance broker | USD $6,314 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | VOLUNTARY LIFE | | Welfare Benefit Premiums Paid to Carrier | USD $33,350 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,314 | | Insurance broker organization code? | 3 | | Insurance broker name | WILLIAM PATRICK SHANNON |
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| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 64548 ) |
| Policy contract number | FLX966138 |
| Policy instance | 11 |
| Insurance contract or identification number | FLX966138 | | Number of Individuals Covered | 208 | | Insurance policy start date | 2014-09-01 | | Insurance policy end date | 2015-07-01 | | Total amount of commissions paid to insurance broker | USD $3,399 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | VOLUNTARY LIFE | | Welfare Benefit Premiums Paid to Carrier | USD $17,752 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,399 | | Insurance broker organization code? | 3 | | Insurance broker name | WILLIAM PATRICK SHANNON |
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| UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 ) |
| Policy contract number | 5454555 |
| Policy instance | 12 |
| Insurance contract or identification number | 5454555 | | Number of Individuals Covered | 139 | | Insurance policy start date | 2015-09-01 | | Insurance policy end date | 2016-04-30 | | Total amount of commissions paid to insurance broker | USD $3,207 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $64,080 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,207 | | Insurance broker organization code? | 3 | | Insurance broker name | JARBOE SHANNON GROUP, LLC |
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| ANTHEM INSURANCE COMPANIES, INC (National Association of Insurance Commissioners NAIC id number: 28207 ) |
| Policy contract number | 00244346 |
| Policy instance | 13 |
| Insurance contract or identification number | 00244346 | | Number of Individuals Covered | 238 | | Insurance policy start date | 2015-05-01 | | Insurance policy end date | 2016-04-30 | | Total amount of commissions paid to insurance broker | USD $35,941 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $987,586 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $35,941 | | Insurance broker organization code? | 3 | | Insurance broker name | USI INSURANCE SERVICES, LLC |
|
| UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 ) |
| Policy contract number | 5299478 |
| Policy instance | 1 |
| Insurance contract or identification number | 5299478 | | Number of Individuals Covered | 234 | | Insurance policy start date | 2013-09-01 | | Insurance policy end date | 2014-08-31 | | Total amount of commissions paid to insurance broker | USD $15,763 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD & D | | Welfare Benefit Premiums Paid to Carrier | USD $144,682 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $15,763 | | Insurance broker organization code? | 3 | | Insurance broker name | JARBOE SHANNON GROUP LLC |
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| UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 ) |
| Policy contract number | 5439984 |
| Policy instance | 2 |
| Insurance contract or identification number | 5439984 | | Number of Individuals Covered | 125 | | Insurance policy start date | 2013-09-01 | | Insurance policy end date | 2014-08-31 | | Total amount of commissions paid to insurance broker | USD $10,942 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $72,944 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $10,942 | | Insurance broker organization code? | 3 | | Insurance broker name | JARBOE SHANNON GROUP LLC |
|
| HUMANA HEALTH PLAN, INC. (National Association of Insurance Commissioners NAIC id number: 95885 ) |
| Policy contract number | 584370 |
| Policy instance | 3 |
| Insurance contract or identification number | 584370 | | Number of Individuals Covered | 125 | | Insurance policy start date | 2014-05-01 | | Insurance policy end date | 2015-04-30 | | Total amount of commissions paid to insurance broker | USD $47,460 | | Total amount of fees paid to insurance company | USD $13,216 | | Health Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,157,378 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $47,460 | | Amount paid for insurance broker fees | 13216 | | Additional information about fees paid to insurance broker | VOLUME INCENTIVE | | Insurance broker organization code? | 3 | | Insurance broker name | USI MIDWEST INC |
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| COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 ) |
| Policy contract number | E7964802 |
| Policy instance | 5 |
| Insurance contract or identification number | E7964802 | | Number of Individuals Covered | 2 | | Insurance policy start date | 2013-09-01 | | Insurance policy end date | 2014-08-31 | | Total amount of commissions paid to insurance broker | USD $894 | | Total amount of fees paid to insurance company | USD $35 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $6,006 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $258 | | Amount paid for insurance broker fees | 23 | | Additional information about fees paid to insurance broker | BONUS PAID | | Insurance broker organization code? | 3 | | Insurance broker name | SUZANNE BRATTON TUCKER |
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| UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 ) |
| Policy contract number | 5454555 |
| Policy instance | 4 |
| Insurance contract or identification number | 5454555 | | Number of Individuals Covered | 155 | | Insurance policy start date | 2013-09-01 | | Insurance policy end date | 2014-08-31 | | Total amount of commissions paid to insurance broker | USD $5,248 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $104,969 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,248 | | Insurance broker organization code? | 3 | | Insurance broker name | JARBOE SHANNON GROUP LLC |
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| COMPBENEFITS (National Association of Insurance Commissioners NAIC id number: 60984 ) |
| Policy contract number | 584370 |
| Policy instance | 6 |
| Insurance contract or identification number | 584370 | | Number of Individuals Covered | 127 | | Insurance policy start date | 2013-05-01 | | Insurance policy end date | 2014-04-30 | | Total amount of commissions paid to insurance broker | USD $1,875 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $18,805 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,875 | | Insurance broker organization code? | 3 | | Insurance broker name | USI MIDWEST INC - LOUISVILLE |
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| COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 ) |
| Policy contract number | E7964802 |
| Policy instance | 1 |
| Insurance contract or identification number | E7964802 | | Number of Individuals Covered | 60 | | Insurance policy start date | 2012-09-01 | | Insurance policy end date | 2013-08-31 | | Total amount of commissions paid to insurance broker | USD $10,427 | | Total amount of fees paid to insurance company | USD $563 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $38,920 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,013 | | Amount paid for insurance broker fees | 372 | | Additional information about fees paid to insurance broker | BONUSES AND NON CASH INCENTIVES | | Insurance broker organization code? | 3 | | Insurance broker name | SUZANNE BRATTON TUCKER |
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| UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 ) |
| Policy contract number | 5439984 |
| Policy instance | 3 |
| Insurance contract or identification number | 5439984 | | Number of Individuals Covered | 110 | | Insurance policy start date | 2012-09-01 | | Insurance policy end date | 2013-08-31 | | Total amount of commissions paid to insurance broker | USD $8,298 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $55,319 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,298 | | Insurance broker organization code? | 3 | | Insurance broker name | JARBOE SHANNON GROUP LLC |
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| UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 ) |
| Policy contract number | 5299478 |
| Policy instance | 2 |
| Insurance contract or identification number | 5299478 | | Number of Individuals Covered | 245 | | Insurance policy start date | 2012-09-01 | | Insurance policy end date | 2013-08-31 | | Total amount of commissions paid to insurance broker | USD $15,117 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD & D | | Welfare Benefit Premiums Paid to Carrier | USD $151,094 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $15,117 | | Insurance broker organization code? | 3 | | Insurance broker name | JARBOE SHANNON GROUP LLC |
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| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 742210 |
| Policy instance | 4 |
| Insurance contract or identification number | 742210 | | Number of Individuals Covered | 237 | | Insurance policy start date | 2013-05-01 | | Insurance policy end date | 2014-04-30 | | Total amount of commissions paid to insurance broker | USD $31,590 | | Total amount of fees paid to insurance company | USD $5,160 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,148,938 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $31,590 | | Amount paid for insurance broker fees | 5160 | | Additional information about fees paid to insurance broker | BONUS AMOUNT | | Insurance broker organization code? | 3 | | Insurance broker name | USI MIDWEST |
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| UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 ) |
| Policy contract number | 5454555 |
| Policy instance | 5 |
| Insurance contract or identification number | 5454555 | | Number of Individuals Covered | 166 | | Insurance policy start date | 2012-09-01 | | Insurance policy end date | 2013-08-31 | | Total amount of commissions paid to insurance broker | USD $5,639 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $112,778 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,639 | | Insurance broker organization code? | 3 | | Insurance broker name | JARBOE SHANNON GROUP LLC |
|
| UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 ) |
| Policy contract number | 5454555 |
| Policy instance | 1 |
| Insurance contract or identification number | 5454555 | | Number of Individuals Covered | 159 | | Insurance policy start date | 2011-09-01 | | Insurance policy end date | 2012-08-31 | | Total amount of commissions paid to insurance broker | USD $4,929 | | Total amount of fees paid to insurance company | USD $1,483 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $98,589 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,929 | | Amount paid for insurance broker fees | 1483 | | Additional information about fees paid to insurance broker | PRODUCER BONUS PROGRAM PAYMENT | | Insurance broker organization code? | 3 | | Insurance broker name | JARBOE SHANNON GROUP LLC |
|
| UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 ) |
| Policy contract number | 5299478 |
| Policy instance | 5 |
| Insurance contract or identification number | 5299478 | | Number of Individuals Covered | 240 | | Insurance policy start date | 2011-09-01 | | Insurance policy end date | 2012-08-31 | | Total amount of commissions paid to insurance broker | USD $14,286 | | Total amount of fees paid to insurance company | USD $4,205 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD & D | | Welfare Benefit Premiums Paid to Carrier | USD $142,856 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $14,286 | | Amount paid for insurance broker fees | 4205 | | Additional information about fees paid to insurance broker | PRODUCER BONUS PROGRAM PAYMENT | | Insurance broker organization code? | 3 | | Insurance broker name | JARBOE SHANNON GROUP LLC |
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| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 742210 |
| Policy instance | 4 |
| Insurance contract or identification number | 742210 | | Number of Individuals Covered | 300 | | Insurance policy start date | 2012-05-01 | | Insurance policy end date | 2013-04-30 | | Total amount of commissions paid to insurance broker | USD $39,256 | | Total amount of fees paid to insurance company | USD $5,040 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,308,445 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $39,256 | | Amount paid for insurance broker fees | 5040 | | Additional information about fees paid to insurance broker | PRODUCER BONUS PAYMENT PROGRAM | | Insurance broker organization code? | 3 | | Insurance broker name | USI MIDWEST |
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| UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 ) |
| Policy contract number | 5439984 |
| Policy instance | 3 |
| Insurance contract or identification number | 5439984 | | Number of Individuals Covered | 88 | | Insurance policy start date | 2011-09-01 | | Insurance policy end date | 2012-08-31 | | Total amount of commissions paid to insurance broker | USD $6,574 | | Total amount of fees paid to insurance company | USD $1,333 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $43,827 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,574 | | Amount paid for insurance broker fees | 1333 | | Additional information about fees paid to insurance broker | PRODUCER BONUS PAYMENT PROGRAM | | Insurance broker organization code? | 3 | | Insurance broker name | JARBOE SHANNON GROUP LLC |
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| COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 ) |
| Policy contract number | E7964802 |
| Policy instance | 2 |
| Insurance contract or identification number | E7964802 | | Number of Individuals Covered | 67 | | Insurance policy start date | 2011-09-01 | | Insurance policy end date | 2012-08-31 | | Total amount of commissions paid to insurance broker | USD $5,166 | | Total amount of fees paid to insurance company | USD $1,361 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $24,533 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,796 | | Amount paid for insurance broker fees | 982 | | Additional information about fees paid to insurance broker | BONUSES AND NON CASH INCENTIVES | | Insurance broker organization code? | 3 | | Insurance broker name | FINCH INSURANCE GROUP LLC |
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| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 742210 |
| Policy instance | 1 |
| Insurance contract or identification number | 742210 | | Number of Individuals Covered | 303 | | Insurance policy start date | 2011-05-01 | | Insurance policy end date | 2012-04-30 | | Total amount of commissions paid to insurance broker | USD $44,366 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,026,057 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 ) |
| Policy contract number | 5299478 |
| Policy instance | 1 |
| Insurance contract or identification number | 5299478 | | Number of Individuals Covered | 207 | | Insurance policy start date | 2010-07-01 | | Insurance policy end date | 2011-06-30 | | Total amount of commissions paid to insurance broker | USD $7,578 | | Total amount of fees paid to insurance company | USD $1,475 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD & D | | Welfare Benefit Premiums Paid to Carrier | USD $94,491 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 ) |
| Policy contract number | 5299478 |
| Policy instance | 1 |
| Insurance contract or identification number | 5299478 | | Number of Individuals Covered | 101 | | Insurance policy start date | 2008-05-01 | | Insurance policy end date | 2009-06-30 | | Total amount of commissions paid to insurance broker | USD $1,011 | | Total amount of fees paid to insurance company | USD $956 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD & D | | Welfare Benefit Premiums Paid to Carrier | USD $10,113 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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| UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 ) |
| Policy contract number | 5299478 |
| Policy instance | 1 |
| Insurance contract or identification number | 5299478 | | Number of Individuals Covered | 117 | | Insurance policy start date | 2007-06-01 | | Insurance policy end date | 2008-04-30 | | Total amount of commissions paid to insurance broker | USD $4,472 | | Total amount of fees paid to insurance company | USD $802 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD & D | | Welfare Benefit Premiums Paid to Carrier | USD $59,340 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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