GOODWILL INDUSTRIES OF NORTHEAST INDIANA, INC. has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan GOODWILL INDUSTRIES OF N.E. INDIANA EMPLOYEE GROUP HEALTH PLAN
401k plan membership statisitcs for GOODWILL INDUSTRIES OF N.E. INDIANA EMPLOYEE GROUP HEALTH PLAN
| Measure | Date | Value |
|---|
| 2021: GOODWILL INDUSTRIES OF N.E. INDIANA EMPLOYEE GROUP HEALTH PLAN 2021 401k membership |
|---|
| Total participants, beginning-of-year | 2021-10-01 | 146 |
| Total number of active participants reported on line 7a of the Form 5500 | 2021-10-01 | 148 |
| Number of retired or separated participants receiving benefits | 2021-10-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2021-10-01 | 0 |
| Total of all active and inactive participants | 2021-10-01 | 148 |
| 2020: GOODWILL INDUSTRIES OF N.E. INDIANA EMPLOYEE GROUP HEALTH PLAN 2020 401k membership |
|---|
| Total participants, beginning-of-year | 2020-10-01 | 143 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-10-01 | 146 |
| Number of retired or separated participants receiving benefits | 2020-10-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2020-10-01 | 0 |
| Total of all active and inactive participants | 2020-10-01 | 146 |
| 2019: GOODWILL INDUSTRIES OF N.E. INDIANA EMPLOYEE GROUP HEALTH PLAN 2019 401k membership |
|---|
| Total participants, beginning-of-year | 2019-10-01 | 143 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-10-01 | 143 |
| Number of retired or separated participants receiving benefits | 2019-10-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2019-10-01 | 0 |
| Total of all active and inactive participants | 2019-10-01 | 143 |
| 2018: GOODWILL INDUSTRIES OF N.E. INDIANA EMPLOYEE GROUP HEALTH PLAN 2018 401k membership |
|---|
| Total participants, beginning-of-year | 2018-10-01 | 132 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-10-01 | 143 |
| Number of retired or separated participants receiving benefits | 2018-10-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2018-10-01 | 0 |
| Total of all active and inactive participants | 2018-10-01 | 143 |
| 2017: GOODWILL INDUSTRIES OF N.E. INDIANA EMPLOYEE GROUP HEALTH PLAN 2017 401k membership |
|---|
| Total participants, beginning-of-year | 2017-10-01 | 137 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-10-01 | 132 |
| Number of retired or separated participants receiving benefits | 2017-10-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2017-10-01 | 0 |
| Total of all active and inactive participants | 2017-10-01 | 132 |
| 2016: GOODWILL INDUSTRIES OF N.E. INDIANA EMPLOYEE GROUP HEALTH PLAN 2016 401k membership |
|---|
| Total participants, beginning-of-year | 2016-10-01 | 104 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-10-01 | 94 |
| Number of retired or separated participants receiving benefits | 2016-10-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2016-10-01 | 0 |
| Total of all active and inactive participants | 2016-10-01 | 94 |
| 2015: GOODWILL INDUSTRIES OF N.E. INDIANA EMPLOYEE GROUP HEALTH PLAN 2015 401k membership |
|---|
| Total participants, beginning-of-year | 2015-10-01 | 110 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-10-01 | 104 |
| Number of retired or separated participants receiving benefits | 2015-10-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2015-10-01 | 0 |
| Total of all active and inactive participants | 2015-10-01 | 104 |
| 2014: GOODWILL INDUSTRIES OF N.E. INDIANA EMPLOYEE GROUP HEALTH PLAN 2014 401k membership |
|---|
| Total participants, beginning-of-year | 2014-10-01 | 138 |
| Total number of active participants reported on line 7a of the Form 5500 | 2014-10-01 | 110 |
| Number of retired or separated participants receiving benefits | 2014-10-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2014-10-01 | 0 |
| Total of all active and inactive participants | 2014-10-01 | 110 |
| 2013: GOODWILL INDUSTRIES OF N.E. INDIANA EMPLOYEE GROUP HEALTH PLAN 2013 401k membership |
|---|
| Total participants, beginning-of-year | 2013-10-01 | 113 |
| Total number of active participants reported on line 7a of the Form 5500 | 2013-10-01 | 138 |
| Total of all active and inactive participants | 2013-10-01 | 138 |
| 2012: GOODWILL INDUSTRIES OF N.E. INDIANA EMPLOYEE GROUP HEALTH PLAN 2012 401k membership |
|---|
| Total participants, beginning-of-year | 2012-10-01 | 118 |
| Total number of active participants reported on line 7a of the Form 5500 | 2012-10-01 | 113 |
| Total of all active and inactive participants | 2012-10-01 | 113 |
| 2011: GOODWILL INDUSTRIES OF N.E. INDIANA EMPLOYEE GROUP HEALTH PLAN 2011 401k membership |
|---|
| Total participants, beginning-of-year | 2011-10-01 | 112 |
| Total number of active participants reported on line 7a of the Form 5500 | 2011-10-01 | 118 |
| Total of all active and inactive participants | 2011-10-01 | 118 |
| Total participants | 2011-10-01 | 118 |
| 2021: GOODWILL INDUSTRIES OF N.E. INDIANA EMPLOYEE GROUP HEALTH PLAN 2021 form 5500 responses |
|---|
| 2021-10-01 | Type of plan entity | Single employer plan |
| 2021-10-01 | Plan funding arrangement – Insurance | Yes |
| 2021-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2021-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2021-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2020: GOODWILL INDUSTRIES OF N.E. INDIANA EMPLOYEE GROUP HEALTH PLAN 2020 form 5500 responses |
|---|
| 2020-10-01 | Type of plan entity | Single employer plan |
| 2020-10-01 | Plan funding arrangement – Insurance | Yes |
| 2020-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2020-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2020-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2019: GOODWILL INDUSTRIES OF N.E. INDIANA EMPLOYEE GROUP HEALTH PLAN 2019 form 5500 responses |
|---|
| 2019-10-01 | Type of plan entity | Single employer plan |
| 2019-10-01 | Plan funding arrangement – Insurance | Yes |
| 2019-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2019-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2019-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2018: GOODWILL INDUSTRIES OF N.E. INDIANA EMPLOYEE GROUP HEALTH PLAN 2018 form 5500 responses |
|---|
| 2018-10-01 | Type of plan entity | Single employer plan |
| 2018-10-01 | Plan funding arrangement – Insurance | Yes |
| 2018-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2018-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2018-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2017: GOODWILL INDUSTRIES OF N.E. INDIANA EMPLOYEE GROUP HEALTH PLAN 2017 form 5500 responses |
|---|
| 2017-10-01 | Type of plan entity | Single employer plan |
| 2017-10-01 | Plan funding arrangement – Insurance | Yes |
| 2017-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2017-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2017-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2016: GOODWILL INDUSTRIES OF N.E. INDIANA EMPLOYEE GROUP HEALTH PLAN 2016 form 5500 responses |
|---|
| 2016-10-01 | Type of plan entity | Single employer plan |
| 2016-10-01 | Plan funding arrangement – Insurance | Yes |
| 2016-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2016-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2016-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2015: GOODWILL INDUSTRIES OF N.E. INDIANA EMPLOYEE GROUP HEALTH PLAN 2015 form 5500 responses |
|---|
| 2015-10-01 | Type of plan entity | Single employer plan |
| 2015-10-01 | Plan funding arrangement – Insurance | Yes |
| 2015-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2015-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2015-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2014: GOODWILL INDUSTRIES OF N.E. INDIANA EMPLOYEE GROUP HEALTH PLAN 2014 form 5500 responses |
|---|
| 2014-10-01 | Type of plan entity | Single employer plan |
| 2014-10-01 | Plan funding arrangement – Insurance | Yes |
| 2014-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2014-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2014-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2013: GOODWILL INDUSTRIES OF N.E. INDIANA EMPLOYEE GROUP HEALTH PLAN 2013 form 5500 responses |
|---|
| 2013-10-01 | Type of plan entity | Single employer plan |
| 2013-10-01 | Plan funding arrangement – Insurance | Yes |
| 2013-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2013-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2013-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2012: GOODWILL INDUSTRIES OF N.E. INDIANA EMPLOYEE GROUP HEALTH PLAN 2012 form 5500 responses |
|---|
| 2012-10-01 | Type of plan entity | Single employer plan |
| 2012-10-01 | Plan funding arrangement – Insurance | Yes |
| 2012-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2012-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2012-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2011: GOODWILL INDUSTRIES OF N.E. INDIANA EMPLOYEE GROUP HEALTH PLAN 2011 form 5500 responses |
|---|
| 2011-10-01 | Type of plan entity | Single employer plan |
| 2011-10-01 | Plan funding arrangement – Insurance | Yes |
| 2011-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2011-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2011-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 10132391001 |
| Policy instance | 2 |
| Insurance contract or identification number | 10132391001 | | Number of Individuals Covered | 92 | | Insurance policy start date | 2021-10-01 | | Insurance policy end date | 2022-09-30 | | Total amount of commissions paid to insurance broker | USD $678 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $6,730 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $678 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AMAF |
| Policy instance | 1 |
| Insurance contract or identification number | G000AMAF | | Number of Individuals Covered | 148 | | Insurance policy start date | 2021-10-01 | | Insurance policy end date | 2022-09-30 | | Total amount of commissions paid to insurance broker | USD $1,360 | | Total amount of fees paid to insurance company | USD $420 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $13,598 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,360 | | Amount paid for insurance broker fees | 420 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 10132391001 |
| Policy instance | 2 |
| Insurance contract or identification number | 10132391001 | | Number of Individuals Covered | 91 | | Insurance policy start date | 2020-10-01 | | Insurance policy end date | 2021-09-30 | | Total amount of commissions paid to insurance broker | USD $792 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $7,338 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $792 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AMAF |
| Policy instance | 1 |
| Insurance contract or identification number | G000AMAF | | Number of Individuals Covered | 146 | | Insurance policy start date | 2020-10-01 | | Insurance policy end date | 2021-09-30 | | Total amount of commissions paid to insurance broker | USD $1,174 | | Total amount of fees paid to insurance company | USD $495 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $11,744 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,174 | | Amount paid for insurance broker fees | 495 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 10132391001 |
| Policy instance | 2 |
| Insurance contract or identification number | 10132391001 | | Number of Individuals Covered | 98 | | Insurance policy start date | 2019-10-01 | | Insurance policy end date | 2020-09-30 | | Total amount of commissions paid to insurance broker | USD $821 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $8,103 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $821 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AMAF |
| Policy instance | 1 |
| Insurance contract or identification number | G000AMAF | | Number of Individuals Covered | 143 | | Insurance policy start date | 2019-10-01 | | Insurance policy end date | 2020-09-30 | | Total amount of commissions paid to insurance broker | USD $1,090 | | Total amount of fees paid to insurance company | USD $358 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $10,896 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,090 | | Amount paid for insurance broker fees | 358 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 10132391001 |
| Policy instance | 3 |
| Insurance contract or identification number | 10132391001 | | Number of Individuals Covered | 107 | | Insurance policy start date | 2018-10-01 | | Insurance policy end date | 2019-09-30 | | Total amount of commissions paid to insurance broker | USD $757 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $7,646 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $757 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AMAF |
| Policy instance | 2 |
| Insurance contract or identification number | G000AMAF | | Number of Individuals Covered | 143 | | Insurance policy start date | 2018-10-01 | | Insurance policy end date | 2019-09-30 | | Total amount of commissions paid to insurance broker | USD $984 | | Total amount of fees paid to insurance company | USD $405 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $9,844 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $984 | | Amount paid for insurance broker fees | 405 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| FAIR AMERICAN INS AND REINS CO. (National Association of Insurance Commissioners NAIC id number: 35157 ) |
| Policy contract number | |
| Policy instance | 1 |
| Number of Individuals Covered | 94 | | Insurance policy start date | 2018-10-01 | | Insurance policy end date | 2019-09-30 | | Total amount of commissions paid to insurance broker | USD $7,079 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $177,058 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,079 | | Insurance broker organization code? | 3 |
|
| FAIR AMERICAN INS AND REINS CO. (National Association of Insurance Commissioners NAIC id number: 35157 ) |
| Policy contract number | |
| Policy instance | 1 |
| Number of Individuals Covered | 84 | | Insurance policy start date | 2017-10-01 | | Insurance policy end date | 2018-09-30 | | Total amount of commissions paid to insurance broker | USD $7,339 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $176,046 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AMAF |
| Policy instance | 2 |
| Insurance contract or identification number | G000AMAF | | Number of Individuals Covered | 132 | | Insurance policy start date | 2017-10-01 | | Insurance policy end date | 2018-10-01 | | Total amount of commissions paid to insurance broker | USD $905 | | Total amount of fees paid to insurance company | USD $426 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $9,051 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AMAF |
| Policy instance | 2 |
| Insurance contract or identification number | G000AMAF | | Number of Individuals Covered | 152 | | Insurance policy start date | 2015-10-01 | | Insurance policy end date | 2016-10-01 | | Total amount of commissions paid to insurance broker | USD $954 | | Total amount of fees paid to insurance company | USD $257 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $9,536 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $954 | | Amount paid for insurance broker fees | 257 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | HYLANT GROUP OF INDIANA LLC |
|
| HCC LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 92711 ) |
| Policy contract number | HCL 14853 |
| Policy instance | 1 |
| Insurance contract or identification number | HCL 14853 | | Number of Individuals Covered | 104 | | Insurance policy start date | 2015-10-01 | | Insurance policy end date | 2016-09-30 | | Total amount of commissions paid to insurance broker | USD $8,405 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $251,357 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,405 | | Insurance broker organization code? | 3 | | Insurance broker name | HYLANT GROUP OF INDIANA LLC |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AMAF |
| Policy instance | 2 |
| Insurance contract or identification number | G000AMAF | | Number of Individuals Covered | 155 | | Insurance policy start date | 2014-10-01 | | Insurance policy end date | 2015-10-01 | | Total amount of commissions paid to insurance broker | USD $662 | | Total amount of fees paid to insurance company | USD $387 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $6,617 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $662 | | Amount paid for insurance broker fees | 387 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | HYLANT GROUP OF INDIANA LLC |
|
| HCC LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 92711 ) |
| Policy contract number | HCL 14853 |
| Policy instance | 1 |
| Insurance contract or identification number | HCL 14853 | | Number of Individuals Covered | 110 | | Insurance policy start date | 2014-10-01 | | Insurance policy end date | 2015-09-30 | | Total amount of commissions paid to insurance broker | USD $8,756 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $294,470 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,756 | | Insurance broker organization code? | 3 | | Insurance broker name | HYLANT GROUP OF INDIANA LLC |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AMAF |
| Policy instance | 2 |
| Insurance contract or identification number | G000AMAF | | Number of Individuals Covered | 138 | | Insurance policy start date | 2013-10-01 | | Insurance policy end date | 2014-10-01 | | Total amount of commissions paid to insurance broker | USD $647 | | Total amount of fees paid to insurance company | USD $287 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $6,470 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $647 | | Amount paid for insurance broker fees | 287 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | HYLANT GROUP OF INDIANA LLC |
|
| HCC LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 92711 ) |
| Policy contract number | HCL 14853 |
| Policy instance | 1 |
| Insurance contract or identification number | HCL 14853 | | Number of Individuals Covered | 103 | | Insurance policy start date | 2013-10-01 | | Insurance policy end date | 2014-09-30 | | Total amount of commissions paid to insurance broker | USD $8,515 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $191,433 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,515 | | Insurance broker organization code? | 3 | | Insurance broker name | HYLANT GROUP OF INDIANA LLC |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AMAF |
| Policy instance | 2 |
| Insurance contract or identification number | G000AMAF | | Number of Individuals Covered | 151 | | Insurance policy start date | 2012-10-01 | | Insurance policy end date | 2013-09-30 | | Total amount of commissions paid to insurance broker | USD $637 | | Total amount of fees paid to insurance company | USD $53 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $6,368 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $637 | | Amount paid for insurance broker fees | 53 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | HYLANT GROUP OF INDIANA LLC |
|
| HCC LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 92711 ) |
| Policy contract number | HCL 14853 |
| Policy instance | 1 |
| Insurance contract or identification number | HCL 14853 | | Number of Individuals Covered | 113 | | Insurance policy start date | 2012-10-01 | | Insurance policy end date | 2013-09-30 | | Total amount of commissions paid to insurance broker | USD $8,944 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $199,210 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,944 | | Insurance broker organization code? | 3 | | Insurance broker name | HYLANT GROUP OF INDIANA LLC |
|
| HCC LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 92711 ) |
| Policy contract number | HCL 14853 |
| Policy instance | 1 |
| Insurance contract or identification number | HCL 14853 | | Number of Individuals Covered | 118 | | Insurance policy start date | 2011-10-01 | | Insurance policy end date | 2012-09-30 | | Total amount of commissions paid to insurance broker | USD $9,113 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $196,367 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
