BLACKHAWK BANK & TRUST has sponsored the creation of one or more 401k plans.
| Measure | Date | Value |
|---|
| 2021: BLACKHAWK BANK & TRUST 2021 401k membership |
|---|
| Total participants, beginning-of-year | 2021-01-01 | 224 |
| Total number of active participants reported on line 7a of the Form 5500 | 2021-01-01 | 211 |
| Total of all active and inactive participants | 2021-01-01 | 211 |
| Total participants | 2021-01-01 | 211 |
| 2020: BLACKHAWK BANK & TRUST 2020 401k membership |
|---|
| Total participants, beginning-of-year | 2020-07-01 | 237 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-07-01 | 206 |
| Number of retired or separated participants receiving benefits | 2020-07-01 | 27 |
| Total of all active and inactive participants | 2020-07-01 | 233 |
| Total participants | 2020-07-01 | 233 |
| Total participants, beginning-of-year | 2020-01-01 | 220 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-01-01 | 224 |
| Total of all active and inactive participants | 2020-01-01 | 224 |
| Total participants | 2020-01-01 | 224 |
| 2019: BLACKHAWK BANK & TRUST 2019 401k membership |
|---|
| Total participants, beginning-of-year | 2019-07-01 | 235 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-07-01 | 209 |
| Number of retired or separated participants receiving benefits | 2019-07-01 | 28 |
| Total of all active and inactive participants | 2019-07-01 | 237 |
| Total participants | 2019-07-01 | 237 |
| Total participants, beginning-of-year | 2019-01-01 | 218 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-01-01 | 220 |
| Number of retired or separated participants receiving benefits | 2019-01-01 | 0 |
| 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 | 220 |
| Total participants | 2019-01-01 | 220 |
| 2018: BLACKHAWK BANK & TRUST 2018 401k membership |
|---|
| Total participants, beginning-of-year | 2018-07-01 | 232 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-07-01 | 204 |
| Number of retired or separated participants receiving benefits | 2018-07-01 | 31 |
| Total of all active and inactive participants | 2018-07-01 | 235 |
| Total participants | 2018-07-01 | 235 |
| Total participants, beginning-of-year | 2018-01-01 | 212 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-01-01 | 218 |
| Number of retired or separated participants receiving benefits | 2018-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2018-01-01 | 0 |
| Total of all active and inactive participants | 2018-01-01 | 218 |
| Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits | 2018-01-01 | 0 |
| Total participants | 2018-01-01 | 218 |
| Number of participants with account balances | 2018-01-01 | 0 |
| Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested | 2018-01-01 | 0 |
| 2017: BLACKHAWK BANK & TRUST 2017 401k membership |
|---|
| Total participants, beginning-of-year | 2017-07-01 | 225 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-07-01 | 203 |
| Number of retired or separated participants receiving benefits | 2017-07-01 | 26 |
| Total of all active and inactive participants | 2017-07-01 | 229 |
| Total participants | 2017-07-01 | 229 |
| Total participants, beginning-of-year | 2017-01-01 | 112 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-01-01 | 119 |
| 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 | 0 |
| Total of all active and inactive participants | 2017-01-01 | 119 |
| Total participants | 2017-01-01 | 119 |
| 2016: BLACKHAWK BANK & TRUST 2016 401k membership |
|---|
| Total participants, beginning-of-year | 2016-07-01 | 221 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-07-01 | 202 |
| Number of retired or separated participants receiving benefits | 2016-07-01 | 19 |
| Total of all active and inactive participants | 2016-07-01 | 221 |
| Total participants | 2016-07-01 | 221 |
| Total participants, beginning-of-year | 2016-01-01 | 104 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-01-01 | 113 |
| Total of all active and inactive participants | 2016-01-01 | 113 |
| Total participants | 2016-01-01 | 113 |
| 2015: BLACKHAWK BANK & TRUST 2015 401k membership |
|---|
| Total participants, beginning-of-year | 2015-07-01 | 212 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-07-01 | 201 |
| Number of retired or separated participants receiving benefits | 2015-07-01 | 18 |
| Total of all active and inactive participants | 2015-07-01 | 219 |
| Total participants | 2015-07-01 | 219 |
| 2014: BLACKHAWK BANK & TRUST 2014 401k membership |
|---|
| Total participants, beginning-of-year | 2014-07-01 | 205 |
| Total number of active participants reported on line 7a of the Form 5500 | 2014-07-01 | 211 |
| Total of all active and inactive participants | 2014-07-01 | 211 |
| Total participants | 2014-07-01 | 211 |
| 2013: BLACKHAWK BANK & TRUST 2013 401k membership |
|---|
| Total participants, beginning-of-year | 2013-07-01 | 195 |
| Total number of active participants reported on line 7a of the Form 5500 | 2013-07-01 | 212 |
| Total of all active and inactive participants | 2013-07-01 | 212 |
| Total participants | 2013-07-01 | 212 |
| 2012: BLACKHAWK BANK & TRUST 2012 401k membership |
|---|
| Total participants, beginning-of-year | 2012-07-01 | 202 |
| Total number of active participants reported on line 7a of the Form 5500 | 2012-07-01 | 195 |
| Number of retired or separated participants receiving benefits | 2012-07-01 | 13 |
| Total of all active and inactive participants | 2012-07-01 | 208 |
| Total participants | 2012-07-01 | 208 |
| 2011: BLACKHAWK BANK & TRUST 2011 401k membership |
|---|
| Total participants, beginning-of-year | 2011-07-01 | 182 |
| Total number of active participants reported on line 7a of the Form 5500 | 2011-07-01 | 201 |
| Number of retired or separated participants receiving benefits | 2011-07-01 | 11 |
| Total of all active and inactive participants | 2011-07-01 | 212 |
| Total participants | 2011-07-01 | 212 |
| 2010: BLACKHAWK BANK & TRUST 2010 401k membership |
|---|
| Total participants, beginning-of-year | 2010-07-01 | 184 |
| Total number of active participants reported on line 7a of the Form 5500 | 2010-07-01 | 188 |
| Number of retired or separated participants receiving benefits | 2010-07-01 | 11 |
| Number of other retired or separated participants entitled to future benefits | 2010-07-01 | 0 |
| Total of all active and inactive participants | 2010-07-01 | 199 |
| Total participants | 2010-07-01 | 199 |
| 2009: BLACKHAWK BANK & TRUST 2009 401k membership |
|---|
| Total participants, beginning-of-year | 2009-07-01 | 184 |
| Total number of active participants reported on line 7a of the Form 5500 | 2009-07-01 | 174 |
| Number of retired or separated participants receiving benefits | 2009-07-01 | 10 |
| Number of other retired or separated participants entitled to future benefits | 2009-07-01 | 0 |
| Total of all active and inactive participants | 2009-07-01 | 184 |
| Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits | 2009-07-01 | 0 |
| Total participants | 2009-07-01 | 184 |
| Number of participants with account balances | 2009-07-01 | 0 |
| Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested | 2009-07-01 | 0 |
| 2021: BLACKHAWK BANK & TRUST 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 | No |
| 2021-01-01 | Plan funding arrangement – Insurance | Yes |
| 2021-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2020: BLACKHAWK BANK & TRUST 2020 form 5500 responses |
|---|
| 2020-07-01 | Type of plan entity | Single employer plan |
| 2020-07-01 | Submission has been amended | No |
| 2020-07-01 | This submission is the final filing | No |
| 2020-07-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2020-07-01 | Plan is a collectively bargained plan | No |
| 2020-07-01 | Plan funding arrangement – Insurance | Yes |
| 2020-07-01 | Plan benefit arrangement – Insurance | Yes |
| 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 | No |
| 2020-01-01 | Plan funding arrangement – Insurance | Yes |
| 2020-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2019: BLACKHAWK BANK & TRUST 2019 form 5500 responses |
|---|
| 2019-07-01 | Type of plan entity | Single employer plan |
| 2019-07-01 | Submission has been amended | No |
| 2019-07-01 | This submission is the final filing | No |
| 2019-07-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2019-07-01 | Plan is a collectively bargained plan | No |
| 2019-07-01 | Plan funding arrangement – Insurance | Yes |
| 2019-07-01 | Plan benefit arrangement – Insurance | Yes |
| 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 | No |
| 2019-01-01 | Plan funding arrangement – Insurance | Yes |
| 2019-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2018: BLACKHAWK BANK & TRUST 2018 form 5500 responses |
|---|
| 2018-07-01 | Type of plan entity | Single employer plan |
| 2018-07-01 | Submission has been amended | No |
| 2018-07-01 | This submission is the final filing | No |
| 2018-07-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2018-07-01 | Plan is a collectively bargained plan | No |
| 2018-07-01 | Plan funding arrangement – Insurance | Yes |
| 2018-07-01 | Plan benefit arrangement – Insurance | Yes |
| 2018-01-01 | Type of plan entity | Single employer plan |
| 2018-01-01 | First time form 5500 has been submitted | Yes |
| 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 | No |
| 2018-01-01 | Plan funding arrangement – Insurance | Yes |
| 2018-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2017: BLACKHAWK BANK & TRUST 2017 form 5500 responses |
|---|
| 2017-07-01 | Type of plan entity | Single employer plan |
| 2017-07-01 | Submission has been amended | No |
| 2017-07-01 | This submission is the final filing | No |
| 2017-07-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2017-07-01 | Plan is a collectively bargained plan | No |
| 2017-07-01 | Plan funding arrangement – Insurance | Yes |
| 2017-07-01 | Plan benefit arrangement – Insurance | Yes |
| 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 | No |
| 2017-01-01 | Plan funding arrangement – Insurance | Yes |
| 2017-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2016: BLACKHAWK BANK & TRUST 2016 form 5500 responses |
|---|
| 2016-07-01 | Type of plan entity | Single employer plan |
| 2016-07-01 | Submission has been amended | No |
| 2016-07-01 | This submission is the final filing | No |
| 2016-07-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2016-07-01 | Plan is a collectively bargained plan | No |
| 2016-07-01 | Plan funding arrangement – Insurance | Yes |
| 2016-07-01 | Plan benefit arrangement – Insurance | Yes |
| 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 | No |
| 2016-01-01 | Plan funding arrangement – Insurance | Yes |
| 2016-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2015: BLACKHAWK BANK & TRUST 2015 form 5500 responses |
|---|
| 2015-07-01 | Type of plan entity | Single employer plan |
| 2015-07-01 | Submission has been amended | No |
| 2015-07-01 | This submission is the final filing | No |
| 2015-07-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2015-07-01 | Plan is a collectively bargained plan | No |
| 2015-07-01 | Plan funding arrangement – Insurance | Yes |
| 2015-07-01 | Plan benefit arrangement – Insurance | Yes |
| 2014: BLACKHAWK BANK & TRUST 2014 form 5500 responses |
|---|
| 2014-07-01 | Type of plan entity | Single employer plan |
| 2014-07-01 | Submission has been amended | No |
| 2014-07-01 | This submission is the final filing | No |
| 2014-07-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2014-07-01 | Plan is a collectively bargained plan | No |
| 2014-07-01 | Plan funding arrangement – Insurance | Yes |
| 2014-07-01 | Plan benefit arrangement – Insurance | Yes |
| 2013: BLACKHAWK BANK & TRUST 2013 form 5500 responses |
|---|
| 2013-07-01 | Type of plan entity | Single employer plan |
| 2013-07-01 | Submission has been amended | No |
| 2013-07-01 | This submission is the final filing | No |
| 2013-07-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2013-07-01 | Plan is a collectively bargained plan | No |
| 2013-07-01 | Plan funding arrangement – Insurance | Yes |
| 2013-07-01 | Plan benefit arrangement – Insurance | Yes |
| 2012: BLACKHAWK BANK & TRUST 2012 form 5500 responses |
|---|
| 2012-07-01 | Type of plan entity | Single employer plan |
| 2012-07-01 | Submission has been amended | No |
| 2012-07-01 | This submission is the final filing | No |
| 2012-07-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2012-07-01 | Plan is a collectively bargained plan | No |
| 2012-07-01 | Plan funding arrangement – Insurance | Yes |
| 2012-07-01 | Plan benefit arrangement – Insurance | Yes |
| 2011: BLACKHAWK BANK & TRUST 2011 form 5500 responses |
|---|
| 2011-07-01 | Type of plan entity | Single employer plan |
| 2011-07-01 | Submission has been amended | No |
| 2011-07-01 | This submission is the final filing | No |
| 2011-07-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2011-07-01 | Plan is a collectively bargained plan | No |
| 2011-07-01 | Plan funding arrangement – Insurance | Yes |
| 2011-07-01 | Plan benefit arrangement – Insurance | Yes |
| 2010: BLACKHAWK BANK & TRUST 2010 form 5500 responses |
|---|
| 2010-07-01 | Type of plan entity | Single employer plan |
| 2010-07-01 | Submission has been amended | No |
| 2010-07-01 | This submission is the final filing | No |
| 2010-07-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2010-07-01 | Plan is a collectively bargained plan | No |
| 2010-07-01 | Plan funding arrangement – Insurance | Yes |
| 2010-07-01 | Plan benefit arrangement – Insurance | Yes |
| 2009: BLACKHAWK BANK & TRUST 2009 form 5500 responses |
|---|
| 2009-07-01 | Type of plan entity | Single employer plan |
| 2009-07-01 | Submission has been amended | No |
| 2009-07-01 | This submission is the final filing | No |
| 2009-07-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2009-07-01 | Plan is a collectively bargained plan | No |
| 2009-07-01 | Plan funding arrangement – Insurance | Yes |
| 2009-07-01 | Plan benefit arrangement – Insurance | Yes |
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 12516 ) |
| Policy contract number | 30105454 |
| Policy instance | 2 |
| Insurance contract or identification number | 30105454 | | Number of Individuals Covered | 85 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $336 | | 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 $3,364 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $336 |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 0509328 |
| Policy instance | 1 |
| Insurance contract or identification number | 0509328 | | Number of Individuals Covered | 211 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-07-31 | | Total amount of commissions paid to insurance broker | USD $7,242 | | 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 | Yes | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | Yes | | 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 $75,412 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,242 |
|
| BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 ) |
| Policy contract number | 344383 |
| Policy instance | 3 |
| Insurance contract or identification number | 344383 | | Number of Individuals Covered | 267 | | Insurance policy start date | 2020-07-01 | | Insurance policy end date | 2021-06-30 | | Total amount of commissions paid to insurance broker | USD $12,162 | | Total amount of fees paid to insurance company | USD $1,208 | | 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 | Yes | | 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 | | 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 $486,270 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $12,162 | | Amount paid for insurance broker fees | 1208 |
|
| DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 ) |
| Policy contract number | MI901657 |
| Policy instance | 2 |
| Insurance contract or identification number | MI901657 | | Number of Individuals Covered | 232 | | Insurance policy start date | 2020-07-01 | | Insurance policy end date | 2021-06-30 | | Total amount of commissions paid to insurance broker | USD $832 | | 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 | 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 $5,691 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $681 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000331G |
| Policy instance | 1 |
| Insurance contract or identification number | G000331G | | Number of Individuals Covered | 232 | | Insurance policy start date | 2020-09-01 | | Insurance policy end date | 2021-09-01 | | Total amount of commissions paid to insurance broker | USD $7,929 | | Total amount of fees paid to insurance company | USD $6,392 | | 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 | 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 $52,437 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,929 | | Amount paid for insurance broker fees | 6392 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 00509328 |
| Policy instance | 1 |
| Insurance contract or identification number | 00509328 | | Number of Individuals Covered | 224 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $10,598 | | 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 | Yes | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | Yes | | 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 $129,259 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $10,598 |
|
| DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 ) |
| Policy contract number | MI901657 |
| Policy instance | 3 |
| Insurance contract or identification number | MI901657 | | Number of Individuals Covered | 202 | | Insurance policy start date | 2019-07-01 | | Insurance policy end date | 2020-06-30 | | Total amount of commissions paid to insurance broker | USD $805 | | 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 | 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 $5,344 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $805 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000331G |
| Policy instance | 1 |
| Insurance contract or identification number | G000331G | | Number of Individuals Covered | 236 | | Insurance policy start date | 2019-09-01 | | Insurance policy end date | 2020-09-01 | | Total amount of commissions paid to insurance broker | USD $7,509 | | Total amount of fees paid to insurance company | USD $5,876 | | 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 | 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 $48,817 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,509 | | Amount paid for insurance broker fees | 5876 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 ) |
| Policy contract number | 344383 |
| Policy instance | 2 |
| Insurance contract or identification number | 344383 | | Number of Individuals Covered | 282 | | Insurance policy start date | 2019-07-01 | | Insurance policy end date | 2020-06-30 | | Total amount of commissions paid to insurance broker | USD $12,304 | | Total amount of fees paid to insurance company | USD $1,215 | | 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 | Yes | | 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 | | 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 $364,836 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $12,304 | | Amount paid for insurance broker fees | 1215 | | Additional information about fees paid to insurance broker | SPECIAL PROGRAMS |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 00509328 |
| Policy instance | 1 |
| Insurance contract or identification number | 00509328 | | Number of Individuals Covered | 220 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $10,440 | | Total amount of fees paid to insurance company | USD $6,655 | | 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 | Yes | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | Yes | | 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 $122,330 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $10,440 | | Amount paid for insurance broker fees | 6655 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000331G |
| Policy instance | 2 |
| Insurance contract or identification number | G000331G | | Number of Individuals Covered | 235 | | Insurance policy start date | 2018-09-01 | | Insurance policy end date | 2019-09-01 | | Total amount of commissions paid to insurance broker | USD $7,269 | | Total amount of fees paid to insurance company | USD $5,711 | | 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 | 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 $47,397 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,269 | | Amount paid for insurance broker fees | 5711 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 ) |
| Policy contract number | MI901657 |
| Policy instance | 1 |
| Insurance contract or identification number | MI901657 | | Number of Individuals Covered | 220 | | Insurance policy start date | 2018-07-01 | | Insurance policy end date | 2019-06-30 | | Total amount of commissions paid to insurance broker | USD $810 | | 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 | Yes | | 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 $5,412 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $810 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 ) |
| Policy contract number | 344383 |
| Policy instance | 3 |
| Insurance contract or identification number | 344383 | | Number of Individuals Covered | 284 | | Insurance policy start date | 2018-07-01 | | Insurance policy end date | 2019-06-30 | | Total amount of commissions paid to insurance broker | USD $12,512 | | Total amount of fees paid to insurance company | USD $1,215 | | 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 | Yes | | 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 | | 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 $334,170 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $12,512 | | Amount paid for insurance broker fees | 1215 | | Additional information about fees paid to insurance broker | SPECIAL PROGRAMS |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 00509328 |
| Policy instance | 1 |
| Insurance contract or identification number | 00509328 | | Number of Individuals Covered | 218 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $10,024 | | Total amount of fees paid to insurance company | USD $5,596 | | 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 | Yes | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | Yes | | 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 $113,503 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $10,024 | | Amount paid for insurance broker fees | 5596 |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 245108 |
| Policy instance | 3 |
| Insurance contract or identification number | 245108 | | Number of Individuals Covered | 213 | | Insurance policy start date | 2017-07-01 | | Insurance policy end date | 2018-06-30 | | Total amount of commissions paid to insurance broker | USD $1,385 | | 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 | Yes | | 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 $11,539 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,385 | | Insurance broker organization code? | 3 | | Insurance broker name | L B BENEFITS |
|
| BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 ) |
| Policy contract number | 344383 |
| Policy instance | 4 |
| Insurance contract or identification number | 344383 | | Number of Individuals Covered | 288 | | Insurance policy start date | 2017-07-01 | | Insurance policy end date | 2018-06-30 | | Total amount of commissions paid to insurance broker | USD $12,408 | | Total amount of fees paid to insurance company | USD $745 | | 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 | Yes | | 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 | | 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 $287,752 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $12,408 | | Amount paid for insurance broker fees | 745 | | Additional information about fees paid to insurance broker | SPECIAL PROGRAMS | | Insurance broker organization code? | 3 | | Insurance broker name | LB BENEFITS |
|
| DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 ) |
| Policy contract number | MI901657 |
| Policy instance | 1 |
| Insurance contract or identification number | MI901657 | | Number of Individuals Covered | 202 | | Insurance policy start date | 2017-07-01 | | Insurance policy end date | 2018-06-30 | | Total amount of commissions paid to insurance broker | USD $795 | | 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 | 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 $5,299 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $795 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | WELLMARK INC |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000331G |
| Policy instance | 2 |
| Insurance contract or identification number | G000331G | | Number of Individuals Covered | 229 | | Insurance policy start date | 2017-09-01 | | Insurance policy end date | 2018-09-01 | | Total amount of commissions paid to insurance broker | USD $7,052 | | Total amount of fees paid to insurance company | USD $4,994 | | 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 | 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 $45,563 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,052 | | Amount paid for insurance broker fees | 4994 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | EMERSON REID LLC |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 00509328 |
| Policy instance | 1 |
| Insurance contract or identification number | 00509328 | | Number of Individuals Covered | 119 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $6,683 | | Total amount of fees paid to insurance company | USD $4,794 | | 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 | Yes | | 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 $88,112 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,683 | | Amount paid for insurance broker fees | 4794 | | Insurance broker organization code? | 3 | | Insurance broker name | LB BENEFITS INC |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000331G |
| Policy instance | 4 |
| Insurance contract or identification number | G000331G | | Number of Individuals Covered | 219 | | Insurance policy start date | 2015-09-01 | | Insurance policy end date | 2016-09-01 | | Total amount of commissions paid to insurance broker | USD $6,144 | | Total amount of fees paid to insurance company | USD $4,502 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | 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 $39,776 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,144 | | Amount paid for insurance broker fees | 4502 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | EMERSON REID LLC |
|
| DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 ) |
| Policy contract number | MI901657 |
| Policy instance | 3 |
| Insurance contract or identification number | MI901657 | | Number of Individuals Covered | 203 | | Insurance policy start date | 2015-07-01 | | Insurance policy end date | 2016-06-30 | | Total amount of commissions paid to insurance broker | USD $776 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | 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 $5,176 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $776 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | WELLMARK INC |
|
| BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 ) |
| Policy contract number | P45537 |
| Policy instance | 2 |
| Insurance contract or identification number | P45537 | | Number of Individuals Covered | 277 | | Insurance policy start date | 2015-07-01 | | Insurance policy end date | 2016-06-30 | | Total amount of commissions paid to insurance broker | USD $9,636 | | Total amount of fees paid to insurance company | USD $1,050 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | Yes | | 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 | | 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 $217,766 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $9,636 | | Amount paid for insurance broker fees | 1050 | | Additional information about fees paid to insurance broker | SPECIAL PROGRAMS | | Insurance broker organization code? | 3 | | Insurance broker name | LB BENEFITS INC |
|
| SUN LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80926 ) |
| Policy contract number | 246-6749-00 |
| Policy instance | 1 |
| Insurance contract or identification number | 246-6749-00 | | Number of Individuals Covered | 199 | | Insurance policy start date | 2015-07-01 | | Insurance policy end date | 2016-07-01 | | Total amount of commissions paid to insurance broker | USD $2,390 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | Yes | | 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 $19,918 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,390 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | LB BENEFITS INC |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000331G |
| Policy instance | 3 |
| Insurance contract or identification number | G000331G | | Number of Individuals Covered | 211 | | Insurance policy start date | 2014-09-01 | | Insurance policy end date | 2015-09-01 | | Total amount of commissions paid to insurance broker | USD $5,738 | | Total amount of fees paid to insurance company | USD $3,205 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | 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 $37,944 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,738 | | Amount paid for insurance broker fees | 3205 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | EMERSON REID LLC |
|
| SUN LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80926 ) |
| Policy contract number | 246674900 |
| Policy instance | 2 |
| Insurance contract or identification number | 246674900 | | Number of Individuals Covered | 199 | | Insurance policy start date | 2014-07-01 | | Insurance policy end date | 2015-07-01 | | Total amount of commissions paid to insurance broker | USD $2,133 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | Yes | | 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 $17,772 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,133 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | L B BENEFITS INC |
|
| DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 ) |
| Policy contract number | MI901657 |
| Policy instance | 1 |
| Insurance contract or identification number | MI901657 | | Number of Individuals Covered | 203 | | Insurance policy start date | 2014-07-01 | | Insurance policy end date | 2015-06-30 | | Total amount of commissions paid to insurance broker | USD $767 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | 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 $5,112 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $767 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | WELLMARK INC |
|
| BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 ) |
| Policy contract number | P45537 |
| Policy instance | 4 |
| Insurance contract or identification number | P45537 | | Number of Individuals Covered | 260 | | Insurance policy start date | 2014-07-01 | | Insurance policy end date | 2015-06-30 | | Total amount of commissions paid to insurance broker | USD $9,257 | | Total amount of fees paid to insurance company | USD $1,043 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | Yes | | 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 | | 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 $204,277 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $9,257 | | Amount paid for insurance broker fees | 1043 | | Additional information about fees paid to insurance broker | SPECIAL PROGRAMS | | Insurance broker organization code? | 3 | | Insurance broker name | L B BENEFITS INC |
|
| SUN LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80926 ) |
| Policy contract number | 246-6749-00 |
| Policy instance | 2 |
| Insurance contract or identification number | 246-6749-00 | | Number of Individuals Covered | 205 | | Insurance policy start date | 2013-07-01 | | Insurance policy end date | 2014-07-01 | | Total amount of commissions paid to insurance broker | USD $1,837 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | Yes | | 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 $15,309 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,837 | | Amount paid for insurance broker fees | 0 | | Insurance broker name | L B BENEFITS INC |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000331G |
| Policy instance | 3 |
| Insurance contract or identification number | G000331G | | Number of Individuals Covered | 212 | | Insurance policy start date | 2013-09-01 | | Insurance policy end date | 2014-09-01 | | Total amount of commissions paid to insurance broker | USD $5,885 | | Total amount of fees paid to insurance company | USD $3,988 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | 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 $38,672 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,885 | | Amount paid for insurance broker fees | 3988 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | EMERSON REID LLC |
|
| BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 ) |
| Policy contract number | |
| Policy instance | 4 |
| Number of Individuals Covered | 262 | | Insurance policy start date | 2013-07-01 | | Insurance policy end date | 2014-06-30 | | Total amount of commissions paid to insurance broker | USD $10,724 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | Yes | | 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 | | 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 | | Commission paid to Insurance Broker | USD $10,724 | | Insurance broker organization code? | 3 | | Insurance broker name | LB BENEFITS INC |
|
| DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 ) |
| Policy contract number | MI901657 |
| Policy instance | 1 |
| Insurance contract or identification number | MI901657 | | Number of Individuals Covered | 204 | | Insurance policy start date | 2013-07-01 | | Insurance policy end date | 2014-06-30 | | Total amount of commissions paid to insurance broker | USD $771 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | 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 $5,171 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $771 | | Amount paid for insurance broker fees | 0 | | Insurance broker name | WELLMARK INC |
|
| DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 ) |
| Policy contract number | MI901657 |
| Policy instance | 1 |
| Insurance contract or identification number | MI901657 | | Number of Individuals Covered | 193 | | Insurance policy start date | 2012-07-01 | | Insurance policy end date | 2013-06-30 | | Total amount of commissions paid to insurance broker | USD $755 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | 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 $5,005 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $755 | | Amount paid for insurance broker fees | 0 | | Insurance broker name | WELLMARK INC |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000331G |
| Policy instance | 2 |
| Insurance contract or identification number | G000331G | | Number of Individuals Covered | 206 | | Insurance policy start date | 2012-09-01 | | Insurance policy end date | 2013-09-01 | | Total amount of commissions paid to insurance broker | USD $5,341 | | Total amount of fees paid to insurance company | USD $2,931 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | 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 $35,120 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,341 | | Amount paid for insurance broker fees | 2931 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | EMERSON REID & CO INC |
|
| SUN LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80926 ) |
| Policy contract number | 246-6749-00 |
| Policy instance | 3 |
| Insurance contract or identification number | 246-6749-00 | | Number of Individuals Covered | 195 | | Insurance policy start date | 2012-07-01 | | Insurance policy end date | 2013-07-01 | | Total amount of commissions paid to insurance broker | USD $1,631 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | Yes | | 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 $13,590 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,631 | | Insurance broker name | L B BENEFITS INC |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000331G |
| Policy instance | 1 |
| Insurance contract or identification number | G000331G | | Number of Individuals Covered | 203 | | Insurance policy start date | 2011-09-01 | | Insurance policy end date | 2012-09-01 | | Total amount of commissions paid to insurance broker | USD $6,907 | | Total amount of fees paid to insurance company | USD $1,688 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $33,751 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| SUN LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80926 ) |
| Policy contract number | 246674900 |
| Policy instance | 3 |
| Insurance contract or identification number | 246674900 | | Number of Individuals Covered | 200 | | Insurance policy start date | 2011-07-01 | | Insurance policy end date | 2012-07-01 | | Total amount of commissions paid to insurance broker | USD $1,546 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $12,886 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 ) |
| Policy contract number | MI901657 |
| Policy instance | 2 |
| Insurance contract or identification number | MI901657 | | Number of Individuals Covered | 201 | | Insurance policy start date | 2011-07-01 | | Insurance policy end date | 2012-06-30 | | Total amount of commissions paid to insurance broker | USD $733 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $4,930 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| TC3 (National Association of Insurance Commissioners NAIC id number: 0 ) |
| Policy contract number | 46000 |
| Policy instance | 1 |
| Insurance contract or identification number | 46000 | | Number of Individuals Covered | 0 | | Insurance policy start date | 2010-07-01 | | Insurance policy end date | 2011-06-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | % OF SAVINGS | | Welfare Benefit Premiums Paid to Carrier | USD $159 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| SUN LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80926 ) |
| Policy contract number | 246-6749-00 |
| Policy instance | 3 |
| Insurance contract or identification number | 246-6749-00 | | Number of Individuals Covered | 182 | | Insurance policy start date | 2010-07-01 | | Insurance policy end date | 2011-07-01 | | Total amount of commissions paid to insurance broker | USD $1,451 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $12,093 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| UNITED HEALTHCARE SERVICES COMPANY (National Association of Insurance Commissioners NAIC id number: 70254 ) |
| Policy contract number | 0SJK |
| Policy instance | 4 |
| Insurance contract or identification number | 0SJK | | Number of Individuals Covered | 216 | | Insurance policy start date | 2010-07-01 | | Insurance policy end date | 2011-06-30 | | Total amount of commissions paid to insurance broker | USD $9,548 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,024,358 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000331G |
| Policy instance | 5 |
| Insurance contract or identification number | G000331G | | Number of Individuals Covered | 190 | | Insurance policy start date | 2010-09-01 | | Insurance policy end date | 2011-09-01 | | Total amount of commissions paid to insurance broker | USD $5,888 | | Total amount of fees paid to insurance company | USD $1,518 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $30,367 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 ) |
| Policy contract number | MI901657 |
| Policy instance | 2 |
| Insurance contract or identification number | MI901657 | | Number of Individuals Covered | 196 | | Insurance policy start date | 2010-07-01 | | Insurance policy end date | 2011-06-30 | | Total amount of commissions paid to insurance broker | USD $686 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $4,571 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
