AQUA AEROBIC SYSTEMS INC has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan 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 |
|---|
| 2023: AQUA AEROBIC SYSTEMS, INC. EMPLOYEE INSURANCE AND BENEFIT PLAN 2023 401k membership |
|---|
| Total participants, beginning-of-year | 2023-01-01 | 144 |
| Total number of active participants reported on line 7a of the Form 5500 | 2023-01-01 | 164 |
| Number of retired or separated participants receiving benefits | 2023-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2023-01-01 | 0 |
| Total of all active and inactive participants | 2023-01-01 | 164 |
| 2022: AQUA AEROBIC SYSTEMS, INC. EMPLOYEE INSURANCE AND BENEFIT PLAN 2022 401k membership |
|---|
| Total participants, beginning-of-year | 2022-01-01 | 145 |
| Total number of active participants reported on line 7a of the Form 5500 | 2022-01-01 | 144 |
| Number of retired or separated participants receiving benefits | 2022-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2022-01-01 | 1 |
| Total of all active and inactive participants | 2022-01-01 | 145 |
| 2021: AQUA AEROBIC SYSTEMS, INC. EMPLOYEE INSURANCE AND BENEFIT PLAN 2021 401k membership |
|---|
| Total participants, beginning-of-year | 2021-01-01 | 145 |
| Total number of active participants reported on line 7a of the Form 5500 | 2021-01-01 | 143 |
| Number of retired or separated participants receiving benefits | 2021-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2021-01-01 | 3 |
| Total of all active and inactive participants | 2021-01-01 | 146 |
| 2020: AQUA AEROBIC SYSTEMS, INC. EMPLOYEE INSURANCE AND BENEFIT PLAN 2020 401k membership |
|---|
| Total participants, beginning-of-year | 2020-01-01 | 154 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-01-01 | 151 |
| Number of retired or separated participants receiving benefits | 2020-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2020-01-01 | 2 |
| Total of all active and inactive participants | 2020-01-01 | 153 |
| 2019: AQUA AEROBIC SYSTEMS, INC. EMPLOYEE INSURANCE AND BENEFIT PLAN 2019 401k membership |
|---|
| Total participants, beginning-of-year | 2019-01-01 | 150 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-01-01 | 148 |
| Number of retired or separated participants receiving benefits | 2019-01-01 | 1 |
| Number of other retired or separated participants entitled to future benefits | 2019-01-01 | 0 |
| Total of all active and inactive participants | 2019-01-01 | 149 |
| 2018: AQUA AEROBIC SYSTEMS, INC. EMPLOYEE INSURANCE AND BENEFIT PLAN 2018 401k membership |
|---|
| Total participants, beginning-of-year | 2018-01-01 | 144 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-01-01 | 137 |
| Number of retired or separated participants receiving benefits | 2018-01-01 | 2 |
| Number of other retired or separated participants entitled to future benefits | 2018-01-01 | 2 |
| Total of all active and inactive participants | 2018-01-01 | 141 |
| 2017: AQUA AEROBIC SYSTEMS, INC. EMPLOYEE INSURANCE AND BENEFIT PLAN 2017 401k membership |
|---|
| Total participants, beginning-of-year | 2017-01-01 | 140 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-01-01 | 142 |
| Number of retired or separated participants receiving benefits | 2017-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2017-01-01 | 1 |
| Total of all active and inactive participants | 2017-01-01 | 143 |
| 2016: AQUA AEROBIC SYSTEMS, INC. EMPLOYEE INSURANCE AND BENEFIT PLAN 2016 401k membership |
|---|
| Total participants, beginning-of-year | 2016-01-01 | 120 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-01-01 | 136 |
| Number of retired or separated participants receiving benefits | 2016-01-01 | 3 |
| Number of other retired or separated participants entitled to future benefits | 2016-01-01 | 7 |
| Total of all active and inactive participants | 2016-01-01 | 146 |
| 2015: AQUA AEROBIC SYSTEMS, INC. EMPLOYEE INSURANCE AND BENEFIT PLAN 2015 401k membership |
|---|
| Total participants, beginning-of-year | 2015-01-01 | 120 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-01-01 | 121 |
| Number of retired or separated participants receiving benefits | 2015-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2015-01-01 | 0 |
| Total of all active and inactive participants | 2015-01-01 | 121 |
| 2014: AQUA AEROBIC SYSTEMS, INC. EMPLOYEE INSURANCE AND BENEFIT PLAN 2014 401k membership |
|---|
| Total participants, beginning-of-year | 2014-01-01 | 127 |
| Total number of active participants reported on line 7a of the Form 5500 | 2014-01-01 | 120 |
| Number of retired or separated participants receiving benefits | 2014-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2014-01-01 | 0 |
| Total of all active and inactive participants | 2014-01-01 | 120 |
| 2013: AQUA AEROBIC SYSTEMS, INC. EMPLOYEE INSURANCE AND BENEFIT PLAN 2013 401k membership |
|---|
| Total participants, beginning-of-year | 2013-01-01 | 140 |
| Total number of active participants reported on line 7a of the Form 5500 | 2013-01-01 | 127 |
| Total of all active and inactive participants | 2013-01-01 | 127 |
| Total participants | 2013-01-01 | 127 |
| 2012: AQUA AEROBIC SYSTEMS, INC. EMPLOYEE INSURANCE AND BENEFIT PLAN 2012 401k membership |
|---|
| Total participants, beginning-of-year | 2012-01-01 | 143 |
| Total number of active participants reported on line 7a of the Form 5500 | 2012-01-01 | 140 |
| Total of all active and inactive participants | 2012-01-01 | 140 |
| Total participants | 2012-01-01 | 140 |
| 2011: AQUA AEROBIC SYSTEMS, INC. EMPLOYEE INSURANCE AND BENEFIT PLAN 2011 401k membership |
|---|
| Total participants, beginning-of-year | 2011-01-01 | 151 |
| Total number of active participants reported on line 7a of the Form 5500 | 2011-01-01 | 143 |
| Total of all active and inactive participants | 2011-01-01 | 143 |
| 2009: AQUA AEROBIC SYSTEMS, INC. EMPLOYEE INSURANCE AND BENEFIT PLAN 2009 401k membership |
|---|
| Total participants, beginning-of-year | 2009-01-01 | 156 |
| Total number of active participants reported on line 7a of the Form 5500 | 2009-01-01 | 147 |
| Total of all active and inactive participants | 2009-01-01 | 147 |
| 2023: AQUA AEROBIC SYSTEMS, INC. EMPLOYEE INSURANCE AND BENEFIT PLAN 2023 form 5500 responses |
|---|
| 2023-01-01 | Type of plan entity | Single employer plan |
| 2023-01-01 | Submission has been amended | No |
| 2023-01-01 | This submission is the final filing | No |
| 2023-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2023-01-01 | Plan is a collectively bargained plan | Yes |
| 2023-01-01 | Plan funding arrangement – Insurance | Yes |
| 2023-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2023-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2023-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2022: AQUA AEROBIC SYSTEMS, INC. EMPLOYEE INSURANCE AND BENEFIT PLAN 2022 form 5500 responses |
|---|
| 2022-01-01 | Type of plan entity | Single employer plan |
| 2022-01-01 | Submission has been amended | No |
| 2022-01-01 | This submission is the final filing | No |
| 2022-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2022-01-01 | Plan is a collectively bargained plan | Yes |
| 2022-01-01 | Plan funding arrangement – Insurance | Yes |
| 2022-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2022-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2022-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2021: AQUA AEROBIC SYSTEMS, INC. EMPLOYEE INSURANCE AND BENEFIT PLAN 2021 form 5500 responses |
|---|
| 2021-01-01 | Type of plan entity | Single employer plan |
| 2021-01-01 | Submission has been amended | No |
| 2021-01-01 | This submission is the final filing | No |
| 2021-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2021-01-01 | Plan is a collectively bargained plan | Yes |
| 2021-01-01 | Plan funding arrangement – Insurance | Yes |
| 2021-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2021-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2021-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2020: AQUA AEROBIC SYSTEMS, INC. EMPLOYEE INSURANCE AND BENEFIT PLAN 2020 form 5500 responses |
|---|
| 2020-01-01 | Type of plan entity | Single employer plan |
| 2020-01-01 | Submission has been amended | No |
| 2020-01-01 | This submission is the final filing | No |
| 2020-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2020-01-01 | Plan is a collectively bargained plan | Yes |
| 2020-01-01 | Plan funding arrangement – Insurance | Yes |
| 2020-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2020-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2020-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2019: AQUA AEROBIC SYSTEMS, INC. EMPLOYEE INSURANCE AND BENEFIT PLAN 2019 form 5500 responses |
|---|
| 2019-01-01 | Type of plan entity | Single employer plan |
| 2019-01-01 | Submission has been amended | No |
| 2019-01-01 | This submission is the final filing | No |
| 2019-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2019-01-01 | Plan is a collectively bargained plan | Yes |
| 2019-01-01 | Plan funding arrangement – Insurance | Yes |
| 2019-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2019-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2019-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2018: AQUA AEROBIC SYSTEMS, INC. EMPLOYEE INSURANCE AND BENEFIT PLAN 2018 form 5500 responses |
|---|
| 2018-01-01 | Type of plan entity | Single employer plan |
| 2018-01-01 | Submission has been amended | No |
| 2018-01-01 | This submission is the final filing | No |
| 2018-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2018-01-01 | Plan is a collectively bargained plan | Yes |
| 2018-01-01 | Plan funding arrangement – Insurance | Yes |
| 2018-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2018-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2018-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2017: AQUA AEROBIC SYSTEMS, INC. EMPLOYEE INSURANCE AND BENEFIT PLAN 2017 form 5500 responses |
|---|
| 2017-01-01 | Type of plan entity | Single employer plan |
| 2017-01-01 | Submission has been amended | No |
| 2017-01-01 | This submission is the final filing | No |
| 2017-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2017-01-01 | Plan is a collectively bargained plan | Yes |
| 2017-01-01 | Plan funding arrangement – Insurance | Yes |
| 2017-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2017-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2017-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2016: AQUA AEROBIC SYSTEMS, INC. EMPLOYEE INSURANCE AND BENEFIT PLAN 2016 form 5500 responses |
|---|
| 2016-01-01 | Type of plan entity | Single employer plan |
| 2016-01-01 | Submission has been amended | No |
| 2016-01-01 | This submission is the final filing | No |
| 2016-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2016-01-01 | Plan is a collectively bargained plan | Yes |
| 2016-01-01 | Plan funding arrangement – Insurance | Yes |
| 2016-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2016-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2016-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2015: AQUA AEROBIC SYSTEMS, INC. EMPLOYEE INSURANCE AND BENEFIT PLAN 2015 form 5500 responses |
|---|
| 2015-01-01 | Type of plan entity | Single employer plan |
| 2015-01-01 | Plan is a collectively bargained plan | Yes |
| 2015-01-01 | Plan funding arrangement – Insurance | Yes |
| 2015-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2015-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2015-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2014: AQUA AEROBIC SYSTEMS, INC. EMPLOYEE INSURANCE AND BENEFIT PLAN 2014 form 5500 responses |
|---|
| 2014-01-01 | Type of plan entity | Single employer plan |
| 2014-01-01 | Submission has been amended | Yes |
| 2014-01-01 | Plan is a collectively bargained plan | Yes |
| 2014-01-01 | Plan funding arrangement – Insurance | Yes |
| 2014-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2014-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2014-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2013: AQUA AEROBIC SYSTEMS, INC. EMPLOYEE INSURANCE AND BENEFIT PLAN 2013 form 5500 responses |
|---|
| 2013-01-01 | Type of plan entity | Single employer plan |
| 2013-01-01 | Plan is a collectively bargained plan | Yes |
| 2013-01-01 | Plan funding arrangement – Insurance | Yes |
| 2013-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2013-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2013-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2012: AQUA AEROBIC SYSTEMS, INC. EMPLOYEE INSURANCE AND BENEFIT PLAN 2012 form 5500 responses |
|---|
| 2012-01-01 | Type of plan entity | Single employer plan |
| 2012-01-01 | Plan is a collectively bargained plan | Yes |
| 2012-01-01 | Plan funding arrangement – Insurance | Yes |
| 2012-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2012-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2012-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2011: AQUA AEROBIC SYSTEMS, INC. EMPLOYEE INSURANCE AND BENEFIT PLAN 2011 form 5500 responses |
|---|
| 2011-01-01 | Type of plan entity | Single employer plan |
| 2011-01-01 | Plan is a collectively bargained plan | Yes |
| 2011-01-01 | Plan funding arrangement – Insurance | Yes |
| 2011-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2011-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2011-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2009: AQUA AEROBIC SYSTEMS, INC. EMPLOYEE INSURANCE AND BENEFIT PLAN 2009 form 5500 responses |
|---|
| 2009-01-01 | Type of plan entity | Single employer plan |
| 2009-01-01 | Submission has been amended | Yes |
| 2009-01-01 | Plan is a collectively bargained plan | Yes |
| 2009-01-01 | Plan funding arrangement – Insurance | Yes |
| 2009-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2009-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2009-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| HARTFORD LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 19682 ) |
| Policy contract number | GTA101195* |
| Policy instance | 3 |
| Insurance contract or identification number | GTA101195* | | Number of Individuals Covered | 164 | | Insurance policy start date | 2023-01-01 | | Insurance policy end date | 2023-12-31 | | 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 plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | 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 Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | BUSINESS 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 Carrier | USD $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 number | SGD601496* |
| Policy instance | 2 |
| Insurance contract or identification number | SGD601496* | | Number of Individuals Covered | 164 | | Insurance policy start date | 2023-01-01 | | Insurance policy end date | 2023-12-31 | | 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 plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | 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 Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL 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 Carrier | USD $85,143 | | 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 number | 96865281001 |
| Policy instance | 1 |
| Insurance contract or identification number | 96865281001 | | Number of Individuals Covered | 345 | | Insurance policy start date | 2023-01-01 | | Insurance policy end date | 2023-12-31 | | 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 plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | 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 Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | 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 Carrier | USD $17,826 | | 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 number | SGD601496* |
| Policy instance | 2 |
| Insurance contract or identification number | SGD601496* | | Number of Individuals Covered | 144 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $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 plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | 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 Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL 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 Carrier | USD $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 fees | 546 | | Additional information about fees paid to insurance broker | OVERRIDE | | Insurance broker organization code? | 3 |
|
| HARTFORD LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 19682 ) |
| Policy contract number | GTA101195* |
| Policy instance | 3 |
| Insurance contract or identification number | GTA101195* | | Number of Individuals Covered | 144 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | 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 plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | 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 Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | BUSINESS 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 Carrier | USD $0 | | 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 number | 96865281001 |
| Policy instance | 1 |
| Insurance contract or identification number | 96865281001 | | Number of Individuals Covered | 320 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $31 | | Total amount of fees paid to insurance company | USD $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 plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | 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 Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | 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 Carrier | USD $13,651 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $31 | | Insurance broker organization code? | 3 |
|
| HARTFORD LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 19682 ) |
| Policy contract number | GTA101195 |
| Policy instance | 3 |
| Insurance contract or identification number | GTA101195 | | Number of Individuals Covered | 143 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $2,097 | | Total amount of fees paid to insurance company | USD $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 plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | 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 Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | BUSINESS 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 Carrier | USD $8,389 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,097 | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | SGD601496* |
| Policy instance | 2 |
| Insurance contract or identification number | SGD601496* | | Number of Individuals Covered | 143 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $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 plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | 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 Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL 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 Carrier | USD $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 fees | 650 | | Additional information about fees paid to insurance broker | OVERRIDE | | Insurance broker organization code? | 3 |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 96865281001 |
| Policy instance | 1 |
| Insurance contract or identification number | 96865281001 | | Number of Individuals Covered | 311 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $128 | | Total amount of fees paid to insurance company | USD $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 plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | 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 Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | 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 Carrier | USD $16,662 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $128 | | Insurance broker organization code? | 3 |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 96865281001 |
| Policy instance | 2 |
| Insurance contract or identification number | 96865281001 | | Number of Individuals Covered | 332 | | Insurance policy start date | 2019-12-01 | | Insurance policy end date | 2020-11-30 | | Total amount of commissions paid to insurance broker | USD $128 | | Total amount of fees paid to insurance company | USD $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 plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | 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 Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | 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 Carrier | USD $16,904 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $128 | | Insurance broker organization code? | 3 |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 96865281001 |
| Policy instance | 3 |
| Insurance contract or identification number | 96865281001 | | Number of Individuals Covered | 335 | | Insurance policy start date | 2020-12-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $10 | | Total amount of fees paid to insurance company | USD $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 plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | 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 Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | 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 Carrier | USD $0 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $10 | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | SGD601496* |
| Policy instance | 4 |
| Insurance contract or identification number | SGD601496* | | Number of Individuals Covered | 151 | | Insurance policy start date | 2020-12-01 | | Insurance policy end date | 2020-12-31 | | 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 plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | 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 Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL 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 Carrier | USD $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 number | GTA101195 |
| Policy instance | 5 |
| Insurance contract or identification number | GTA101195 | | Number of Individuals Covered | 151 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $933 | | Total amount of fees paid to insurance company | USD $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 plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | 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 Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | BUSINESS 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 Carrier | USD $3,733 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $933 | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | SGM601608* |
| Policy instance | 1 |
| Insurance contract or identification number | SGM601608* | | Number of Individuals Covered | 151 | | Insurance policy start date | 2019-12-01 | | Insurance policy end date | 2020-11-30 | | 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 plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | 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 Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL 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 Carrier | USD $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 number | 96865281001 |
| Policy instance | 2 |
| Insurance contract or identification number | 96865281001 | | Number of Individuals Covered | 359 | | Insurance policy start date | 2018-12-01 | | Insurance policy end date | 2019-11-30 | | Total amount of commissions paid to insurance broker | USD $129 | | Total amount of fees paid to insurance company | USD $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 plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | 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 Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | 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 Carrier | USD $17,222 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $129 | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | SGM601608* |
| Policy instance | 1 |
| Insurance contract or identification number | SGM601608* | | Number of Individuals Covered | 148 | | Insurance policy start date | 2018-12-01 | | Insurance policy end date | 2019-11-30 | | 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 plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | 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 Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL 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 Carrier | USD $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 number | SGM601608* |
| Policy instance | 1 |
| Insurance contract or identification number | SGM601608* | | Number of Individuals Covered | 137 | | Insurance policy start date | 2017-12-01 | | Insurance policy end date | 2018-11-30 | | 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 plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | 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 Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL 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 Carrier | USD $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 number | 96865281001 |
| Policy instance | 2 |
| Insurance contract or identification number | 96865281001 | | Number of Individuals Covered | 378 | | Insurance policy start date | 2017-12-01 | | Insurance policy end date | 2018-11-30 | | Total amount of commissions paid to insurance broker | USD $153 | | Total amount of fees paid to insurance company | USD $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 plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | 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 Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | 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 Carrier | USD $16,631 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $153 | | Insurance broker organization code? | 3 |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 96865281001 |
| Policy instance | 2 |
| Insurance contract or identification number | 96865281001 | | Number of Individuals Covered | 352 | | Insurance policy start date | 2016-12-01 | | Insurance policy end date | 2017-11-30 | | Total amount of commissions paid to insurance broker | USD $98 | | Total amount of fees paid to insurance company | USD $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 plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | 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 Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | 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 Carrier | USD $17,938 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $98 | | Insurance broker organization code? | 3 | | Insurance broker name | WILLIS HRH - MILWAUKEE WI |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | SGM601608* |
| Policy instance | 1 |
| Insurance contract or identification number | SGM601608* | | Number of Individuals Covered | 142 | | Insurance policy start date | 2016-12-01 | | Insurance policy end date | 2017-11-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $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 plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | 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 Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL 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 Carrier | USD $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 fees | 1100 | | Additional information about fees paid to insurance broker | OVERRIDE | | Insurance broker organization code? | 3 | | Insurance broker name | WILLIS OF WISCONSIN INC |
|
| HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93440 ) |
| Policy contract number | 403903-A |
| Policy instance | 1 |
| Insurance contract or identification number | 403903-A | | Number of Individuals Covered | 117 | | Insurance policy start date | 2014-12-01 | | Insurance policy end date | 2015-11-30 | | Welfare Benefit Premiums Paid to Carrier | USD $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 name | WILLIS OF WISCONSIN |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | SGM601608 |
| Policy instance | 2 |
| Insurance contract or identification number | SGM601608 | | Number of Individuals Covered | 121 | | Insurance policy start date | 2014-12-01 | | Insurance policy end date | 2015-11-30 | | Total amount of fees paid to insurance company | USD $214 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $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 fees | 214 | | Additional information about fees paid to insurance broker | SUPP. COMMISSION | | Insurance broker organization code? | 3 | | Insurance broker name | WILLIS OF WI INC |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | SGD601495 |
| Policy instance | 3 |
| Insurance contract or identification number | SGD601495 | | Number of Individuals Covered | 13 | | Insurance policy start date | 2014-12-01 | | Insurance policy end date | 2015-11-30 | | Total amount of fees paid to insurance company | USD $15 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $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 fees | 15 | | Additional information about fees paid to insurance broker | SUPP COMMISSION | | Insurance broker organization code? | 3 | | Insurance broker name | WILLIS OF WI INC. |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | SGD601496 |
| Policy instance | 4 |
| Insurance contract or identification number | SGD601496 | | Number of Individuals Covered | 115 | | Insurance policy start date | 2014-12-01 | | Insurance policy end date | 2015-11-30 | | Total amount of fees paid to insurance company | USD $74 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $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 fees | 74 | | Additional information about fees paid to insurance broker | SUPP COMMISSION | | Insurance broker organization code? | 3 | | Insurance broker name | WILLIS OF WI INC |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | SOK600932 |
| Policy instance | 5 |
| Insurance contract or identification number | SOK600932 | | Number of Individuals Covered | 121 | | Insurance policy start date | 2014-12-01 | | Insurance policy end date | 2015-11-30 | | Total amount of fees paid to insurance company | USD $11 | | Other welfare benefits provided | ACCIDENTAL DEATH / MEDICAL INDEMNIT | | Welfare Benefit Premiums Paid to Carrier | USD $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 fees | 11 | | Additional information about fees paid to insurance broker | SUPP COMMISSION | | Insurance broker organization code? | 3 | | Insurance broker name | WILLIS OF WI INC |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 9686528 |
| Policy instance | 6 |
| Insurance contract or identification number | 9686528 | | Number of Individuals Covered | 262 | | Insurance policy start date | 2014-12-01 | | Insurance policy end date | 2015-11-30 | | Total amount of fees paid to insurance company | USD $88 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $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 fees | 88 | | Insurance broker organization code? | 3 | | Insurance broker name | WILLIS HRH |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 9686528 |
| Policy instance | 6 |
| Insurance contract or identification number | 9686528 | | Number of Individuals Covered | 269 | | Insurance policy start date | 2013-12-01 | | Insurance policy end date | 2014-11-30 | | Total amount of commissions paid to insurance broker | USD $1,581 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $26,535 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $87 | | Insurance broker organization code? | 3 | | Insurance broker name | WILLIS HRH |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | SOK600932 |
| Policy instance | 5 |
| Insurance contract or identification number | SOK600932 | | Number of Individuals Covered | 120 | | Insurance policy start date | 2013-12-01 | | Insurance policy end date | 2014-11-30 | | Total amount of commissions paid to insurance broker | USD $1 | | Total amount of fees paid to insurance company | USD $10 | | Other welfare benefits provided | ACCIDENTAL DEATH / MEDICAL INDEMNIT | | Welfare Benefit Premiums Paid to Carrier | USD $1,431 | | 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 | | Amount paid for insurance broker fees | 10 | | Additional information about fees paid to insurance broker | SUPP COMMISSION | | Insurance broker organization code? | 3 | | Insurance broker name | WILLIS OF WI INC |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | SGD601496 |
| Policy instance | 4 |
| Insurance contract or identification number | SGD601496 | | Number of Individuals Covered | 114 | | Insurance policy start date | 2013-12-01 | | Insurance policy end date | 2014-11-30 | | Total amount of commissions paid to insurance broker | USD $4 | | Total amount of fees paid to insurance company | USD $78 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $10,080 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4 | | Amount paid for insurance broker fees | 78 | | Additional information about fees paid to insurance broker | SUPP COMMISSION | | Insurance broker organization code? | 3 | | Insurance broker name | WILLIS OF WI INC |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | SGD601495 |
| Policy instance | 3 |
| Insurance contract or identification number | SGD601495 | | Number of Individuals Covered | 14 | | Insurance policy start date | 2013-12-01 | | Insurance policy end date | 2014-11-30 | | Total amount of fees paid to insurance company | USD $18 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $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 fees | 18 | | Additional information about fees paid to insurance broker | SUPP COMMISSION | | Insurance broker organization code? | 3 | | Insurance broker name | WILLIS OF WI INC. |
|
| HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93440 ) |
| Policy contract number | 403903-A |
| Policy instance | 1 |
| Insurance contract or identification number | 403903-A | | Number of Individuals Covered | 120 | | Insurance policy start date | 2013-12-01 | | Insurance policy end date | 2014-11-30 | | Welfare Benefit Premiums Paid to Carrier | USD $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 name | WILLIS OF WISCONSIN |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | SGM601608 |
| Policy instance | 2 |
| Insurance contract or identification number | SGM601608 | | Number of Individuals Covered | 120 | | Insurance policy start date | 2013-12-01 | | Insurance policy end date | 2014-11-30 | | Total amount of commissions paid to insurance broker | USD $13 | | Total amount of fees paid to insurance company | USD $223 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $28,436 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $13 | | Amount paid for insurance broker fees | 223 | | Additional information about fees paid to insurance broker | SUPP. COMMISSION | | Insurance broker organization code? | 3 | | Insurance broker name | WILLIS OF WI INC |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | SGM601608 |
| Policy instance | 2 |
| Insurance contract or identification number | SGM601608 | | Number of Individuals Covered | 127 | | Insurance policy start date | 2012-12-01 | | Insurance policy end date | 2013-11-30 | | Total amount of commissions paid to insurance broker | USD $103 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $30,835 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $103 | | Additional information about fees paid to insurance broker | SUPP. COMMISSION | | Insurance broker organization code? | 3 | | Insurance broker name | WILLIS OF WI INC |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | SGD601495 |
| Policy instance | 3 |
| Insurance contract or identification number | SGD601495 | | Number of Individuals Covered | 15 | | Insurance policy start date | 2012-12-01 | | Insurance policy end date | 2013-11-30 | | Total amount of commissions paid to insurance broker | USD $7 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $2,225 | | 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 | | Additional information about fees paid to insurance broker | SUPP COMMISSION | | Insurance broker organization code? | 3 | | Insurance broker name | WILLIS OF WI INC. |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | SGD601496 |
| Policy instance | 4 |
| Insurance contract or identification number | SGD601496 | | Number of Individuals Covered | 121 | | Insurance policy start date | 2012-12-01 | | Insurance policy end date | 2013-11-30 | | Total amount of commissions paid to insurance broker | USD $34 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $10,636 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $34 | | Additional information about fees paid to insurance broker | SUPP COMMISSION | | Insurance broker organization code? | 3 | | Insurance broker name | WILLIS OF WI INC |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | SOK600932 |
| Policy instance | 5 |
| Insurance contract or identification number | SOK600932 | | Number of Individuals Covered | 127 | | Insurance policy start date | 2012-12-01 | | Insurance policy end date | 2013-11-30 | | Total amount of commissions paid to insurance broker | USD $4 | | Other welfare benefits provided | ACCIDENTAL DEATH / MEDICAL INDEMNIT | | Welfare Benefit Premiums Paid to Carrier | USD $1,337 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4 | | Additional information about fees paid to insurance broker | SUPP COMMISSION | | Insurance broker organization code? | 3 | | Insurance broker name | WILLIS OF WI INC |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 9686528 |
| Policy instance | 6 |
| Insurance contract or identification number | 9686528 | | Number of Individuals Covered | 279 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $1,494 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $13,575 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,494 | | Insurance broker organization code? | 3 | | Insurance broker name | WILLIS HRH |
|
| HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93440 ) |
| Policy contract number | 403903-A |
| Policy instance | 1 |
| Insurance contract or identification number | 403903-A | | Number of Individuals Covered | 119 | | Insurance policy start date | 2012-12-01 | | Insurance policy end date | 2013-11-30 | | Welfare Benefit Premiums Paid to Carrier | USD $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 name | WILLIS OF WI, INC |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 9686528 |
| Policy instance | 7 |
| Insurance contract or identification number | 9686528 | | Number of Individuals Covered | 323 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $1,772 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $16,663 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,772 | | Insurance broker organization code? | 3 | | Insurance broker name | WILLIS HRH |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | SOK600932 |
| Policy instance | 6 |
| Insurance contract or identification number | SOK600932 | | Number of Individuals Covered | 139 | | Insurance policy start date | 2011-12-01 | | Insurance policy end date | 2012-12-01 | | Total amount of commissions paid to insurance broker | USD $259 | | Other welfare benefits provided | ACCIDENTAL DEATH / MEDICAL INDEMNIT | | Welfare Benefit Premiums Paid to Carrier | USD $1,613 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $242 | | Additional information about fees paid to insurance broker | SALES & SERVICE | | Insurance broker organization code? | 3 | | Insurance broker name | WILLIS OF WI INC |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | SGD601496 |
| Policy instance | 5 |
| Insurance contract or identification number | SGD601496 | | Number of Individuals Covered | 133 | | Insurance policy start date | 2011-12-01 | | Insurance policy end date | 2012-12-01 | | Total amount of commissions paid to insurance broker | USD $2,184 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $13,626 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,044 | | Additional information about fees paid to insurance broker | SALES & SERVICE | | Insurance broker organization code? | 3 | | Insurance broker name | WILLIS OF WI INC |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | SGD601495 |
| Policy instance | 4 |
| Insurance contract or identification number | SGD601495 | | Number of Individuals Covered | 16 | | Insurance policy start date | 2011-12-01 | | Insurance policy end date | 2012-12-01 | | Total amount of commissions paid to insurance broker | USD $310 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,909 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $286 | | Additional information about fees paid to insurance broker | SALES & SERVICE | | Insurance broker organization code? | 3 | | Insurance broker name | WILLIS OF WI INC. |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | |
| Policy instance | 2 |
| Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-01-31 | | Total amount of commissions paid to insurance broker | USD $-45 | | Welfare Benefit Premiums Paid to Carrier | USD $-227 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $-34 | | Insurance broker organization code? | 3 | | Insurance broker name | UMR |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | SGM601608 |
| Policy instance | 3 |
| Insurance contract or identification number | SGM601608 | | Number of Individuals Covered | 140 | | Insurance policy start date | 2011-12-01 | | Insurance policy end date | 2012-12-01 | | Total amount of commissions paid to insurance broker | USD $6,437 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $40,246 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,037 | | Additional information about fees paid to insurance broker | SALES & SERVICE | | Insurance broker organization code? | 3 | | Insurance broker name | WILLIS OF WI INC |
|
| HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: ) |
| Policy contract number | 403903-A |
| Policy instance | 1 |
| Insurance contract or identification number | 403903-A | | Number of Individuals Covered | 134 | | Insurance policy start date | 2011-12-01 | | Insurance policy end date | 2012-11-30 | | Total amount of commissions paid to insurance broker | USD $41,559 | | Welfare Benefit Premiums Paid to Carrier | USD $277,491 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $41,559 | | Insurance broker organization code? | 3 | | Insurance broker name | WILLIS OF WI, INC |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | SGD601496 |
| Policy instance | 5 |
| Insurance contract or identification number | SGD601496 | | Number of Individuals Covered | 137 | | Insurance policy start date | 2010-12-01 | | Insurance policy end date | 2011-12-01 | | Total amount of commissions paid to insurance broker | USD $2,312 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $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 number | 403903-A |
| Policy instance | 1 |
| Insurance contract or identification number | 403903-A | | Number of Individuals Covered | 143 | | Insurance policy start date | 2011-12-01 | | Insurance policy end date | 2012-11-30 | | Total amount of commissions paid to insurance broker | USD $3,638 | | Total amount of fees paid to insurance company | USD $3,393 | | Welfare Benefit Premiums Paid to Carrier | USD $24,249 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | |
| Policy instance | 2 |
| Number of Individuals Covered | 144 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2011-11-30 | | Total amount of commissions paid to insurance broker | USD $58,393 | | Welfare Benefit Premiums Paid to Carrier | USD $291,969 | | 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 number | SGM601608 |
| Policy instance | 3 |
| Insurance contract or identification number | SGM601608 | | Number of Individuals Covered | 149 | | Insurance policy start date | 2010-12-01 | | Insurance policy end date | 2011-12-01 | | Total amount of commissions paid to insurance broker | USD $6,455 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $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 number | SGD601495 |
| Policy instance | 4 |
| Insurance contract or identification number | SGD601495 | | Number of Individuals Covered | 19 | | Insurance policy start date | 2010-12-01 | | Insurance policy end date | 2011-12-01 | | Total amount of commissions paid to insurance broker | USD $467 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $2,889 | | 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 number | SOK600932 |
| Policy instance | 6 |
| Insurance contract or identification number | SOK600932 | | Number of Individuals Covered | 149 | | Insurance policy start date | 2010-12-01 | | Insurance policy end date | 2011-12-01 | | Total amount of commissions paid to insurance broker | USD $284 | | Other welfare benefits provided | ACCIDENTAL DEATH MEDICAL INDEMNIT | | Welfare Benefit Premiums Paid to Carrier | USD $1,774 | | 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 number | 9686528 |
| Policy instance | 7 |
| Insurance contract or identification number | 9686528 | | Number of Individuals Covered | 350 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2011-12-31 | | Total amount of commissions paid to insurance broker | USD $1,773 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $17,718 | | 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 number | 9686528 |
| Policy instance | 7 |
| Insurance contract or identification number | 9686528 | | Number of Individuals Covered | 371 | | Insurance policy start date | 2010-01-01 | | Insurance policy end date | 2010-12-31 | | Total amount of commissions paid to insurance broker | USD $1,803 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $18,127 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,803 | | Insurance broker name | HRH WISCONSIN INC |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | SOK600932 |
| Policy instance | 6 |
| Insurance contract or identification number | SOK600932 | | Number of Individuals Covered | 156 | | Insurance policy start date | 2009-12-01 | | Insurance policy end date | 2010-12-01 | | Total amount of commissions paid to insurance broker | USD $296 | | Other welfare benefits provided | ACCIDENTAL DEATH MEDICAL INDEMNIT | | Welfare Benefit Premiums Paid to Carrier | USD $1,857 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $279 | | Additional information about fees paid to insurance broker | SALES SERVICE | | Insurance broker name | WILLIS OF WI INC |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | SGD601496 |
| Policy instance | 5 |
| Insurance contract or identification number | SGD601496 | | Number of Individuals Covered | 143 | | Insurance policy start date | 2009-12-01 | | Insurance policy end date | 2010-12-01 | | Total amount of commissions paid to insurance broker | USD $2,295 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $14,415 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,162 | | Additional information about fees paid to insurance broker | SALES SERVICE | | Insurance broker name | WILLIS OF WI INC |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | SGD601495 |
| Policy instance | 4 |
| Insurance contract or identification number | SGD601495 | | Number of Individuals Covered | 21 | | Insurance policy start date | 2009-12-01 | | Insurance policy end date | 2010-12-01 | | Total amount of commissions paid to insurance broker | USD $603 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $3,815 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $572 | | Additional information about fees paid to insurance broker | SALES SERVICE | | Insurance broker name | WILLIS OF WI INC. |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | SGM601608 |
| Policy instance | 3 |
| Insurance contract or identification number | SGM601608 | | Number of Individuals Covered | 135 | | Insurance policy start date | 2009-12-01 | | Insurance policy end date | 2010-12-01 | | Total amount of commissions paid to insurance broker | USD $6,164 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $38,763 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,815 | | Additional information about fees paid to insurance broker | SALES SERVICE | | Insurance broker name | WILLIS 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 Covered | 151 | | Insurance policy start date | 2010-12-01 | | Insurance policy end date | 2010-12-31 | | Total amount of commissions paid to insurance broker | USD $5,617 | | Welfare Benefit Premiums Paid to Carrier | USD $28,090 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,213 | | Insurance broker name | UMR |
|
| HCC LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 92711 ) |
| Policy contract number | |
| Policy instance | 1 |
| Number of Individuals Covered | 151 | | Insurance policy start date | 2010-01-01 | | Insurance policy end date | 2010-11-30 | | Total amount of commissions paid to insurance broker | USD $56,832 | | Welfare Benefit Premiums Paid to Carrier | USD $284,162 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $42,624 | | Insurance broker name | UMR, INC. |
|
