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AQUA AEROBIC SYSTEMS, INC. EMPLOYEE INSURANCE AND BENEFIT PLAN 401k Plan overview

Plan NameAQUA AEROBIC SYSTEMS, INC. EMPLOYEE INSURANCE AND BENEFIT PLAN
Plan identification number 502

AQUA AEROBIC SYSTEMS, INC. EMPLOYEE INSURANCE AND BENEFIT PLAN Benefits

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

401k Sponsoring company profile

AQUA AEROBIC SYSTEMS INC has sponsored the creation of one or more 401k plans.

Company Name:AQUA AEROBIC SYSTEMS INC
Employer identification number (EIN):361795700
NAIC Classification:333310

Form 5500 Filing Information

Submission information for form 5500 for 401k plan AQUA AEROBIC SYSTEMS, INC. EMPLOYEE INSURANCE AND BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5022022-01-01
5022021-01-01
5022020-01-01
5022019-01-01
5022018-01-01
5022017-01-01PAMELA K. APPINO PAMELA K APPINO2018-07-17
5022016-01-01PAMELA K. APPINO
5022015-01-01CHRISTOPHER V. KORAB
5022014-01-01CHRISTOPHER V. KORAB
5022014-01-01CHRISTOPHER V. KORAB
5022013-01-01CHRISTOPHER V. KORAB
5022012-01-01CHRISTOPHER V. KORAB
5022011-01-01CHRISTOPHER V. KORAB
5022009-01-01CHRISTOPHER V. KORAB
5022009-01-01CHRISTOPHER V. KORAB
5022009-01-01CHRISTOPHER V. KORAB
5022009-01-01CHRISTOPHER V. KORAB
5022009-01-01CHRISTOPHER V. KORAB

Plan Statistics for AQUA AEROBIC SYSTEMS, INC. EMPLOYEE INSURANCE AND BENEFIT PLAN

401k plan membership statisitcs for AQUA AEROBIC SYSTEMS, INC. EMPLOYEE INSURANCE AND BENEFIT PLAN

Measure Date Value
2022: AQUA AEROBIC SYSTEMS, INC. EMPLOYEE INSURANCE AND BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year2022-01-01145
Total number of active participants reported on line 7a of the Form 55002022-01-01144
Number of retired or separated participants receiving benefits2022-01-010
Number of other retired or separated participants entitled to future benefits2022-01-011
Total of all active and inactive participants2022-01-01145
2021: AQUA AEROBIC SYSTEMS, INC. EMPLOYEE INSURANCE AND BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year2021-01-01145
Total number of active participants reported on line 7a of the Form 55002021-01-01143
Number of retired or separated participants receiving benefits2021-01-010
Number of other retired or separated participants entitled to future benefits2021-01-013
Total of all active and inactive participants2021-01-01146
2020: AQUA AEROBIC SYSTEMS, INC. EMPLOYEE INSURANCE AND BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year2020-01-01154
Total number of active participants reported on line 7a of the Form 55002020-01-01151
Number of retired or separated participants receiving benefits2020-01-010
Number of other retired or separated participants entitled to future benefits2020-01-012
Total of all active and inactive participants2020-01-01153
2019: AQUA AEROBIC SYSTEMS, INC. EMPLOYEE INSURANCE AND BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year2019-01-01150
Total number of active participants reported on line 7a of the Form 55002019-01-01148
Number of retired or separated participants receiving benefits2019-01-011
Number of other retired or separated participants entitled to future benefits2019-01-010
Total of all active and inactive participants2019-01-01149
2018: AQUA AEROBIC SYSTEMS, INC. EMPLOYEE INSURANCE AND BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year2018-01-01144
Total number of active participants reported on line 7a of the Form 55002018-01-01137
Number of retired or separated participants receiving benefits2018-01-012
Number of other retired or separated participants entitled to future benefits2018-01-012
Total of all active and inactive participants2018-01-01141
2017: AQUA AEROBIC SYSTEMS, INC. EMPLOYEE INSURANCE AND BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year2017-01-01140
Total number of active participants reported on line 7a of the Form 55002017-01-01142
Number of retired or separated participants receiving benefits2017-01-010
Number of other retired or separated participants entitled to future benefits2017-01-011
Total of all active and inactive participants2017-01-01143
2016: AQUA AEROBIC SYSTEMS, INC. EMPLOYEE INSURANCE AND BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year2016-01-01120
Total number of active participants reported on line 7a of the Form 55002016-01-01136
Number of retired or separated participants receiving benefits2016-01-013
Number of other retired or separated participants entitled to future benefits2016-01-017
Total of all active and inactive participants2016-01-01146
2015: AQUA AEROBIC SYSTEMS, INC. EMPLOYEE INSURANCE AND BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year2015-01-01120
Total number of active participants reported on line 7a of the Form 55002015-01-01121
Number of retired or separated participants receiving benefits2015-01-010
Number of other retired or separated participants entitled to future benefits2015-01-010
Total of all active and inactive participants2015-01-01121
2014: AQUA AEROBIC SYSTEMS, INC. EMPLOYEE INSURANCE AND BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year2014-01-01127
Total number of active participants reported on line 7a of the Form 55002014-01-01120
Number of retired or separated participants receiving benefits2014-01-010
Number of other retired or separated participants entitled to future benefits2014-01-010
Total of all active and inactive participants2014-01-01120
2013: AQUA AEROBIC SYSTEMS, INC. EMPLOYEE INSURANCE AND BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year2013-01-01140
Total number of active participants reported on line 7a of the Form 55002013-01-01127
Total of all active and inactive participants2013-01-01127
Total participants2013-01-01127
2012: AQUA AEROBIC SYSTEMS, INC. EMPLOYEE INSURANCE AND BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year2012-01-01143
Total number of active participants reported on line 7a of the Form 55002012-01-01140
Total of all active and inactive participants2012-01-01140
Total participants2012-01-01140
2011: AQUA AEROBIC SYSTEMS, INC. EMPLOYEE INSURANCE AND BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year2011-01-01151
Total number of active participants reported on line 7a of the Form 55002011-01-01143
Total of all active and inactive participants2011-01-01143
2009: AQUA AEROBIC SYSTEMS, INC. EMPLOYEE INSURANCE AND BENEFIT PLAN 2009 401k membership
Total participants, beginning-of-year2009-01-01156
Total number of active participants reported on line 7a of the Form 55002009-01-01147
Total of all active and inactive participants2009-01-01147

Form 5500 Responses for AQUA AEROBIC SYSTEMS, INC. EMPLOYEE INSURANCE AND BENEFIT PLAN

2022: AQUA AEROBIC SYSTEMS, INC. EMPLOYEE INSURANCE AND BENEFIT PLAN 2022 form 5500 responses
2022-01-01Type of plan entitySingle employer plan
2022-01-01Submission has been amendedNo
2022-01-01This submission is the final filingNo
2022-01-01This return/report is a short plan year return/report (less than 12 months)No
2022-01-01Plan is a collectively bargained planYes
2022-01-01Plan funding arrangement – InsuranceYes
2022-01-01Plan funding arrangement – General assets of the sponsorYes
2022-01-01Plan benefit arrangement – InsuranceYes
2022-01-01Plan benefit arrangement – General assets of the sponsorYes
2021: AQUA AEROBIC SYSTEMS, INC. EMPLOYEE INSURANCE AND BENEFIT PLAN 2021 form 5500 responses
2021-01-01Type of plan entitySingle employer plan
2021-01-01Submission has been amendedNo
2021-01-01This submission is the final filingNo
2021-01-01This return/report is a short plan year return/report (less than 12 months)No
2021-01-01Plan is a collectively bargained planYes
2021-01-01Plan funding arrangement – InsuranceYes
2021-01-01Plan funding arrangement – General assets of the sponsorYes
2021-01-01Plan benefit arrangement – InsuranceYes
2021-01-01Plan benefit arrangement – General assets of the sponsorYes
2020: AQUA AEROBIC SYSTEMS, INC. EMPLOYEE INSURANCE AND BENEFIT PLAN 2020 form 5500 responses
2020-01-01Type of plan entitySingle employer plan
2020-01-01Submission has been amendedNo
2020-01-01This submission is the final filingNo
2020-01-01This return/report is a short plan year return/report (less than 12 months)No
2020-01-01Plan is a collectively bargained planYes
2020-01-01Plan funding arrangement – InsuranceYes
2020-01-01Plan funding arrangement – General assets of the sponsorYes
2020-01-01Plan benefit arrangement – InsuranceYes
2020-01-01Plan benefit arrangement – General assets of the sponsorYes
2019: AQUA AEROBIC SYSTEMS, INC. EMPLOYEE INSURANCE AND BENEFIT PLAN 2019 form 5500 responses
2019-01-01Type of plan entitySingle employer plan
2019-01-01Submission has been amendedNo
2019-01-01This submission is the final filingNo
2019-01-01This return/report is a short plan year return/report (less than 12 months)No
2019-01-01Plan is a collectively bargained planYes
2019-01-01Plan funding arrangement – InsuranceYes
2019-01-01Plan funding arrangement – General assets of the sponsorYes
2019-01-01Plan benefit arrangement – InsuranceYes
2019-01-01Plan benefit arrangement – General assets of the sponsorYes
2018: AQUA AEROBIC SYSTEMS, INC. EMPLOYEE INSURANCE AND BENEFIT PLAN 2018 form 5500 responses
2018-01-01Type of plan entitySingle employer plan
2018-01-01Submission has been amendedNo
2018-01-01This submission is the final filingNo
2018-01-01This return/report is a short plan year return/report (less than 12 months)No
2018-01-01Plan is a collectively bargained planYes
2018-01-01Plan funding arrangement – InsuranceYes
2018-01-01Plan funding arrangement – General assets of the sponsorYes
2018-01-01Plan benefit arrangement – InsuranceYes
2018-01-01Plan benefit arrangement – General assets of the sponsorYes
2017: AQUA AEROBIC SYSTEMS, INC. EMPLOYEE INSURANCE AND BENEFIT PLAN 2017 form 5500 responses
2017-01-01Type of plan entitySingle employer plan
2017-01-01Submission has been amendedNo
2017-01-01This submission is the final filingNo
2017-01-01This return/report is a short plan year return/report (less than 12 months)No
2017-01-01Plan is a collectively bargained planYes
2017-01-01Plan funding arrangement – InsuranceYes
2017-01-01Plan funding arrangement – General assets of the sponsorYes
2017-01-01Plan benefit arrangement – InsuranceYes
2017-01-01Plan benefit arrangement – General assets of the sponsorYes
2016: AQUA AEROBIC SYSTEMS, INC. EMPLOYEE INSURANCE AND BENEFIT PLAN 2016 form 5500 responses
2016-01-01Type of plan entitySingle employer plan
2016-01-01Submission has been amendedNo
2016-01-01This submission is the final filingNo
2016-01-01This return/report is a short plan year return/report (less than 12 months)No
2016-01-01Plan is a collectively bargained planYes
2016-01-01Plan funding arrangement – InsuranceYes
2016-01-01Plan funding arrangement – General assets of the sponsorYes
2016-01-01Plan benefit arrangement – InsuranceYes
2016-01-01Plan benefit arrangement – General assets of the sponsorYes
2015: AQUA AEROBIC SYSTEMS, INC. EMPLOYEE INSURANCE AND BENEFIT PLAN 2015 form 5500 responses
2015-01-01Type of plan entitySingle employer plan
2015-01-01Plan is a collectively bargained planYes
2015-01-01Plan funding arrangement – InsuranceYes
2015-01-01Plan funding arrangement – General assets of the sponsorYes
2015-01-01Plan benefit arrangement – InsuranceYes
2015-01-01Plan benefit arrangement – General assets of the sponsorYes
2014: AQUA AEROBIC SYSTEMS, INC. EMPLOYEE INSURANCE AND BENEFIT PLAN 2014 form 5500 responses
2014-01-01Type of plan entitySingle employer plan
2014-01-01Submission has been amendedYes
2014-01-01Plan is a collectively bargained planYes
2014-01-01Plan funding arrangement – InsuranceYes
2014-01-01Plan funding arrangement – General assets of the sponsorYes
2014-01-01Plan benefit arrangement – InsuranceYes
2014-01-01Plan benefit arrangement – General assets of the sponsorYes
2013: AQUA AEROBIC SYSTEMS, INC. EMPLOYEE INSURANCE AND BENEFIT PLAN 2013 form 5500 responses
2013-01-01Type of plan entitySingle employer plan
2013-01-01Plan is a collectively bargained planYes
2013-01-01Plan funding arrangement – InsuranceYes
2013-01-01Plan funding arrangement – General assets of the sponsorYes
2013-01-01Plan benefit arrangement – InsuranceYes
2013-01-01Plan benefit arrangement – General assets of the sponsorYes
2012: AQUA AEROBIC SYSTEMS, INC. EMPLOYEE INSURANCE AND BENEFIT PLAN 2012 form 5500 responses
2012-01-01Type of plan entitySingle employer plan
2012-01-01Plan is a collectively bargained planYes
2012-01-01Plan funding arrangement – InsuranceYes
2012-01-01Plan funding arrangement – General assets of the sponsorYes
2012-01-01Plan benefit arrangement – InsuranceYes
2012-01-01Plan benefit arrangement – General assets of the sponsorYes
2011: AQUA AEROBIC SYSTEMS, INC. EMPLOYEE INSURANCE AND BENEFIT PLAN 2011 form 5500 responses
2011-01-01Type of plan entitySingle employer plan
2011-01-01Plan is a collectively bargained planYes
2011-01-01Plan funding arrangement – InsuranceYes
2011-01-01Plan funding arrangement – General assets of the sponsorYes
2011-01-01Plan benefit arrangement – InsuranceYes
2011-01-01Plan benefit arrangement – General assets of the sponsorYes
2009: AQUA AEROBIC SYSTEMS, INC. EMPLOYEE INSURANCE AND BENEFIT PLAN 2009 form 5500 responses
2009-01-01Type of plan entitySingle employer plan
2009-01-01Submission has been amendedYes
2009-01-01Plan is a collectively bargained planYes
2009-01-01Plan funding arrangement – InsuranceYes
2009-01-01Plan funding arrangement – General assets of the sponsorYes
2009-01-01Plan benefit arrangement – InsuranceYes
2009-01-01Plan benefit arrangement – General assets of the sponsorYes

Insurance Providers Used on plan

HARTFORD LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 19682 )
Policy contract numberGTA101195*
Policy instance 3
Insurance contract or identification numberGTA101195*
Number of Individuals Covered144
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedBUSINESS TRAVEL ACCIDENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $0
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: 65498 )
Policy contract numberSGD601496*
Policy instance 2
Insurance contract or identification numberSGD601496*
Number of Individuals Covered144
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $546
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH & DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $104,367
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Amount paid for insurance broker fees546
Additional information about fees paid to insurance brokerOVERRIDE
Insurance broker organization code?3
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number96865281001
Policy instance 1
Insurance contract or identification number96865281001
Number of Individuals Covered320
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $31
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $13,651
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $31
Insurance broker organization code?3
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number96865281001
Policy instance 1
Insurance contract or identification number96865281001
Number of Individuals Covered311
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $128
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $16,662
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $128
Insurance broker organization code?3
HARTFORD LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 19682 )
Policy contract numberGTA101195
Policy instance 3
Insurance contract or identification numberGTA101195
Number of Individuals Covered143
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $2,097
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedBUSINESS TRAVEL ACCIDENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $8,389
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,097
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberSGD601496*
Policy instance 2
Insurance contract or identification numberSGD601496*
Number of Individuals Covered143
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $650
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH & DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $48,518
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Amount paid for insurance broker fees650
Additional information about fees paid to insurance brokerOVERRIDE
Insurance broker organization code?3
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number96865281001
Policy instance 2
Insurance contract or identification number96865281001
Number of Individuals Covered332
Insurance policy start date2019-12-01
Insurance policy end date2020-11-30
Total amount of commissions paid to insurance brokerUSD $128
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $16,904
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $128
Insurance broker organization code?3
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number96865281001
Policy instance 3
Insurance contract or identification number96865281001
Number of Individuals Covered335
Insurance policy start date2020-12-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $10
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $10
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberSGD601496*
Policy instance 4
Insurance contract or identification numberSGD601496*
Number of Individuals Covered151
Insurance policy start date2020-12-01
Insurance policy end date2020-12-31
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH & DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $5,718
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
HARTFORD LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 19682 )
Policy contract numberGTA101195
Policy instance 5
Insurance contract or identification numberGTA101195
Number of Individuals Covered151
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $933
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedBUSINESS TRAVEL ACCIDENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $3,733
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $933
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberSGM601608*
Policy instance 1
Insurance contract or identification numberSGM601608*
Number of Individuals Covered151
Insurance policy start date2019-12-01
Insurance policy end date2020-11-30
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $76,265
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number96865281001
Policy instance 2
Insurance contract or identification number96865281001
Number of Individuals Covered359
Insurance policy start date2018-12-01
Insurance policy end date2019-11-30
Total amount of commissions paid to insurance brokerUSD $129
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $17,222
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $129
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberSGM601608*
Policy instance 1
Insurance contract or identification numberSGM601608*
Number of Individuals Covered148
Insurance policy start date2018-12-01
Insurance policy end date2019-11-30
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $60,163
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: 65498 )
Policy contract numberSGM601608*
Policy instance 1
Insurance contract or identification numberSGM601608*
Number of Individuals Covered137
Insurance policy start date2017-12-01
Insurance policy end date2018-11-30
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $54,555
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number96865281001
Policy instance 2
Insurance contract or identification number96865281001
Number of Individuals Covered378
Insurance policy start date2017-12-01
Insurance policy end date2018-11-30
Total amount of commissions paid to insurance brokerUSD $153
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $16,631
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $153
Insurance broker organization code?3
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number96865281001
Policy instance 2
Insurance contract or identification number96865281001
Number of Individuals Covered352
Insurance policy start date2016-12-01
Insurance policy end date2017-11-30
Total amount of commissions paid to insurance brokerUSD $98
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $17,938
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $98
Insurance broker organization code?3
Insurance broker nameWILLIS HRH - MILWAUKEE WI
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberSGM601608*
Policy instance 1
Insurance contract or identification numberSGM601608*
Number of Individuals Covered142
Insurance policy start date2016-12-01
Insurance policy end date2017-11-30
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $1,100
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $8,288
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Amount paid for insurance broker fees1100
Additional information about fees paid to insurance brokerOVERRIDE
Insurance broker organization code?3
Insurance broker nameWILLIS OF WISCONSIN INC
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberSGD601496
Policy instance 4
Insurance contract or identification numberSGD601496
Number of Individuals Covered115
Insurance policy start date2014-12-01
Insurance policy end date2015-11-30
Total amount of fees paid to insurance companyUSD $74
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $9,893
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Amount paid for insurance broker fees74
Additional information about fees paid to insurance brokerSUPP COMMISSION
Insurance broker organization code?3
Insurance broker nameWILLIS OF WI INC
HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93440 )
Policy contract number403903-A
Policy instance 1
Insurance contract or identification number403903-A
Number of Individuals Covered117
Insurance policy start date2014-12-01
Insurance policy end date2015-11-30
Welfare Benefit Premiums Paid to CarrierUSD $257,744
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Insurance broker organization code?3
Insurance broker nameWILLIS OF WISCONSIN
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberSGM601608
Policy instance 2
Insurance contract or identification numberSGM601608
Number of Individuals Covered121
Insurance policy start date2014-12-01
Insurance policy end date2015-11-30
Total amount of fees paid to insurance companyUSD $214
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $27,754
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Amount paid for insurance broker fees214
Additional information about fees paid to insurance brokerSUPP. COMMISSION
Insurance broker organization code?3
Insurance broker nameWILLIS OF WI INC
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberSGD601495
Policy instance 3
Insurance contract or identification numberSGD601495
Number of Individuals Covered13
Insurance policy start date2014-12-01
Insurance policy end date2015-11-30
Total amount of fees paid to insurance companyUSD $15
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $4,102
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Amount paid for insurance broker fees15
Additional information about fees paid to insurance brokerSUPP COMMISSION
Insurance broker organization code?3
Insurance broker nameWILLIS OF WI INC.
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberSOK600932
Policy instance 5
Insurance contract or identification numberSOK600932
Number of Individuals Covered121
Insurance policy start date2014-12-01
Insurance policy end date2015-11-30
Total amount of fees paid to insurance companyUSD $11
Other welfare benefits providedACCIDENTAL DEATH / MEDICAL INDEMNIT
Welfare Benefit Premiums Paid to CarrierUSD $1,424
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Amount paid for insurance broker fees11
Additional information about fees paid to insurance brokerSUPP COMMISSION
Insurance broker organization code?3
Insurance broker nameWILLIS OF WI INC
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number9686528
Policy instance 6
Insurance contract or identification number9686528
Number of Individuals Covered262
Insurance policy start date2014-12-01
Insurance policy end date2015-11-30
Total amount of fees paid to insurance companyUSD $88
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $11,803
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Amount paid for insurance broker fees88
Insurance broker organization code?3
Insurance broker nameWILLIS HRH
HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93440 )
Policy contract number403903-A
Policy instance 1
Insurance contract or identification number403903-A
Number of Individuals Covered120
Insurance policy start date2013-12-01
Insurance policy end date2014-11-30
Welfare Benefit Premiums Paid to CarrierUSD $260,469
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Insurance broker organization code?3
Insurance broker nameWILLIS OF WISCONSIN
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberSGD601495
Policy instance 3
Insurance contract or identification numberSGD601495
Number of Individuals Covered14
Insurance policy start date2013-12-01
Insurance policy end date2014-11-30
Total amount of fees paid to insurance companyUSD $18
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,678
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Amount paid for insurance broker fees18
Additional information about fees paid to insurance brokerSUPP COMMISSION
Insurance broker organization code?3
Insurance broker nameWILLIS OF WI INC.
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberSGD601496
Policy instance 4
Insurance contract or identification numberSGD601496
Number of Individuals Covered114
Insurance policy start date2013-12-01
Insurance policy end date2014-11-30
Total amount of commissions paid to insurance brokerUSD $4
Total amount of fees paid to insurance companyUSD $78
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $10,080
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4
Amount paid for insurance broker fees78
Additional information about fees paid to insurance brokerSUPP COMMISSION
Insurance broker organization code?3
Insurance broker nameWILLIS OF WI INC
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number9686528
Policy instance 6
Insurance contract or identification number9686528
Number of Individuals Covered269
Insurance policy start date2013-12-01
Insurance policy end date2014-11-30
Total amount of commissions paid to insurance brokerUSD $1,581
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $26,535
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $87
Insurance broker organization code?3
Insurance broker nameWILLIS HRH
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberSOK600932
Policy instance 5
Insurance contract or identification numberSOK600932
Number of Individuals Covered120
Insurance policy start date2013-12-01
Insurance policy end date2014-11-30
Total amount of commissions paid to insurance brokerUSD $1
Total amount of fees paid to insurance companyUSD $10
Other welfare benefits providedACCIDENTAL DEATH / MEDICAL INDEMNIT
Welfare Benefit Premiums Paid to CarrierUSD $1,431
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1
Amount paid for insurance broker fees10
Additional information about fees paid to insurance brokerSUPP COMMISSION
Insurance broker organization code?3
Insurance broker nameWILLIS OF WI INC
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberSGM601608
Policy instance 2
Insurance contract or identification numberSGM601608
Number of Individuals Covered120
Insurance policy start date2013-12-01
Insurance policy end date2014-11-30
Total amount of commissions paid to insurance brokerUSD $13
Total amount of fees paid to insurance companyUSD $223
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $28,436
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $13
Amount paid for insurance broker fees223
Additional information about fees paid to insurance brokerSUPP. COMMISSION
Insurance broker organization code?3
Insurance broker nameWILLIS OF WI INC
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberSGM601608
Policy instance 2
Insurance contract or identification numberSGM601608
Number of Individuals Covered127
Insurance policy start date2012-12-01
Insurance policy end date2013-11-30
Total amount of commissions paid to insurance brokerUSD $103
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $30,835
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $103
Additional information about fees paid to insurance brokerSUPP. COMMISSION
Insurance broker organization code?3
Insurance broker nameWILLIS OF WI INC
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number9686528
Policy instance 6
Insurance contract or identification number9686528
Number of Individuals Covered279
Insurance policy start date2013-01-01
Insurance policy end date2013-12-31
Total amount of commissions paid to insurance brokerUSD $1,494
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $13,575
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,494
Insurance broker organization code?3
Insurance broker nameWILLIS HRH
HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93440 )
Policy contract number403903-A
Policy instance 1
Insurance contract or identification number403903-A
Number of Individuals Covered119
Insurance policy start date2012-12-01
Insurance policy end date2013-11-30
Welfare Benefit Premiums Paid to CarrierUSD $244,608
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Insurance broker organization code?3
Insurance broker nameWILLIS OF WI, INC
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberSOK600932
Policy instance 5
Insurance contract or identification numberSOK600932
Number of Individuals Covered127
Insurance policy start date2012-12-01
Insurance policy end date2013-11-30
Total amount of commissions paid to insurance brokerUSD $4
Other welfare benefits providedACCIDENTAL DEATH / MEDICAL INDEMNIT
Welfare Benefit Premiums Paid to CarrierUSD $1,337
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4
Additional information about fees paid to insurance brokerSUPP COMMISSION
Insurance broker organization code?3
Insurance broker nameWILLIS OF WI INC
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberSGD601496
Policy instance 4
Insurance contract or identification numberSGD601496
Number of Individuals Covered121
Insurance policy start date2012-12-01
Insurance policy end date2013-11-30
Total amount of commissions paid to insurance brokerUSD $34
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $10,636
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $34
Additional information about fees paid to insurance brokerSUPP COMMISSION
Insurance broker organization code?3
Insurance broker nameWILLIS OF WI INC
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberSGD601495
Policy instance 3
Insurance contract or identification numberSGD601495
Number of Individuals Covered15
Insurance policy start date2012-12-01
Insurance policy end date2013-11-30
Total amount of commissions paid to insurance brokerUSD $7
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $2,225
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $7
Additional information about fees paid to insurance brokerSUPP COMMISSION
Insurance broker organization code?3
Insurance broker nameWILLIS OF WI INC.
HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: )
Policy contract number403903-A
Policy instance 1
Insurance contract or identification number403903-A
Number of Individuals Covered134
Insurance policy start date2011-12-01
Insurance policy end date2012-11-30
Total amount of commissions paid to insurance brokerUSD $41,559
Welfare Benefit Premiums Paid to CarrierUSD $277,491
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $41,559
Insurance broker organization code?3
Insurance broker nameWILLIS OF WI, INC
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberSGD601495
Policy instance 4
Insurance contract or identification numberSGD601495
Number of Individuals Covered16
Insurance policy start date2011-12-01
Insurance policy end date2012-12-01
Total amount of commissions paid to insurance brokerUSD $310
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,909
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $286
Additional information about fees paid to insurance brokerSALES & SERVICE
Insurance broker organization code?3
Insurance broker nameWILLIS OF WI INC.
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberSGD601496
Policy instance 5
Insurance contract or identification numberSGD601496
Number of Individuals Covered133
Insurance policy start date2011-12-01
Insurance policy end date2012-12-01
Total amount of commissions paid to insurance brokerUSD $2,184
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $13,626
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,044
Additional information about fees paid to insurance brokerSALES & SERVICE
Insurance broker organization code?3
Insurance broker nameWILLIS OF WI INC
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberSOK600932
Policy instance 6
Insurance contract or identification numberSOK600932
Number of Individuals Covered139
Insurance policy start date2011-12-01
Insurance policy end date2012-12-01
Total amount of commissions paid to insurance brokerUSD $259
Other welfare benefits providedACCIDENTAL DEATH / MEDICAL INDEMNIT
Welfare Benefit Premiums Paid to CarrierUSD $1,613
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $242
Additional information about fees paid to insurance brokerSALES & SERVICE
Insurance broker organization code?3
Insurance broker nameWILLIS OF WI INC
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number9686528
Policy instance 7
Insurance contract or identification number9686528
Number of Individuals Covered323
Insurance policy start date2012-01-01
Insurance policy end date2012-12-31
Total amount of commissions paid to insurance brokerUSD $1,772
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $16,663
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,772
Insurance broker organization code?3
Insurance broker nameWILLIS HRH
SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )
Policy contract number
Policy instance 2
Insurance policy start date2012-01-01
Insurance policy end date2012-01-31
Total amount of commissions paid to insurance brokerUSD $-45
Welfare Benefit Premiums Paid to CarrierUSD $-227
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $-34
Insurance broker organization code?3
Insurance broker nameUMR
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberSGM601608
Policy instance 3
Insurance contract or identification numberSGM601608
Number of Individuals Covered140
Insurance policy start date2011-12-01
Insurance policy end date2012-12-01
Total amount of commissions paid to insurance brokerUSD $6,437
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $40,246
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6,037
Additional information about fees paid to insurance brokerSALES & SERVICE
Insurance broker organization code?3
Insurance broker nameWILLIS OF WI INC
SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )
Policy contract number
Policy instance 2
Number of Individuals Covered144
Insurance policy start date2011-01-01
Insurance policy end date2011-11-30
Total amount of commissions paid to insurance brokerUSD $58,393
Welfare Benefit Premiums Paid to CarrierUSD $291,969
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number9686528
Policy instance 7
Insurance contract or identification number9686528
Number of Individuals Covered350
Insurance policy start date2011-01-01
Insurance policy end date2011-12-31
Total amount of commissions paid to insurance brokerUSD $1,773
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $17,718
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: 65498 )
Policy contract numberSOK600932
Policy instance 6
Insurance contract or identification numberSOK600932
Number of Individuals Covered149
Insurance policy start date2010-12-01
Insurance policy end date2011-12-01
Total amount of commissions paid to insurance brokerUSD $284
Other welfare benefits providedACCIDENTAL DEATH MEDICAL INDEMNIT
Welfare Benefit Premiums Paid to CarrierUSD $1,774
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: 65498 )
Policy contract numberSGD601496
Policy instance 5
Insurance contract or identification numberSGD601496
Number of Individuals Covered137
Insurance policy start date2010-12-01
Insurance policy end date2011-12-01
Total amount of commissions paid to insurance brokerUSD $2,312
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $14,452
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: )
Policy contract number403903-A
Policy instance 1
Insurance contract or identification number403903-A
Number of Individuals Covered143
Insurance policy start date2011-12-01
Insurance policy end date2012-11-30
Total amount of commissions paid to insurance brokerUSD $3,638
Total amount of fees paid to insurance companyUSD $3,393
Welfare Benefit Premiums Paid to CarrierUSD $24,249
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: 65498 )
Policy contract numberSGM601608
Policy instance 3
Insurance contract or identification numberSGM601608
Number of Individuals Covered149
Insurance policy start date2010-12-01
Insurance policy end date2011-12-01
Total amount of commissions paid to insurance brokerUSD $6,455
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $40,370
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: 65498 )
Policy contract numberSGD601495
Policy instance 4
Insurance contract or identification numberSGD601495
Number of Individuals Covered19
Insurance policy start date2010-12-01
Insurance policy end date2011-12-01
Total amount of commissions paid to insurance brokerUSD $467
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $2,889
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
HCC LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 92711 )
Policy contract number
Policy instance 1
Number of Individuals Covered151
Insurance policy start date2010-01-01
Insurance policy end date2010-11-30
Total amount of commissions paid to insurance brokerUSD $56,832
Welfare Benefit Premiums Paid to CarrierUSD $284,162
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $42,624
Insurance broker nameUMR, INC.
SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )
Policy contract number
Policy instance 2
Number of Individuals Covered151
Insurance policy start date2010-12-01
Insurance policy end date2010-12-31
Total amount of commissions paid to insurance brokerUSD $5,617
Welfare Benefit Premiums Paid to CarrierUSD $28,090
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,213
Insurance broker nameUMR
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberSGM601608
Policy instance 3
Insurance contract or identification numberSGM601608
Number of Individuals Covered135
Insurance policy start date2009-12-01
Insurance policy end date2010-12-01
Total amount of commissions paid to insurance brokerUSD $6,164
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $38,763
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,815
Additional information about fees paid to insurance brokerSALES SERVICE
Insurance broker nameWILLIS OF WI INC
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberSGD601495
Policy instance 4
Insurance contract or identification numberSGD601495
Number of Individuals Covered21
Insurance policy start date2009-12-01
Insurance policy end date2010-12-01
Total amount of commissions paid to insurance brokerUSD $603
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $3,815
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $572
Additional information about fees paid to insurance brokerSALES SERVICE
Insurance broker nameWILLIS OF WI INC.
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number9686528
Policy instance 7
Insurance contract or identification number9686528
Number of Individuals Covered371
Insurance policy start date2010-01-01
Insurance policy end date2010-12-31
Total amount of commissions paid to insurance brokerUSD $1,803
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $18,127
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,803
Insurance broker nameHRH WISCONSIN INC
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberSOK600932
Policy instance 6
Insurance contract or identification numberSOK600932
Number of Individuals Covered156
Insurance policy start date2009-12-01
Insurance policy end date2010-12-01
Total amount of commissions paid to insurance brokerUSD $296
Other welfare benefits providedACCIDENTAL DEATH MEDICAL INDEMNIT
Welfare Benefit Premiums Paid to CarrierUSD $1,857
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $279
Additional information about fees paid to insurance brokerSALES SERVICE
Insurance broker nameWILLIS OF WI INC
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberSGD601496
Policy instance 5
Insurance contract or identification numberSGD601496
Number of Individuals Covered143
Insurance policy start date2009-12-01
Insurance policy end date2010-12-01
Total amount of commissions paid to insurance brokerUSD $2,295
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $14,415
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,162
Additional information about fees paid to insurance brokerSALES SERVICE
Insurance broker nameWILLIS OF WI INC

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