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UNITED LABORATORIES, INC. EMPLOYEE BENEFITS PLAN 401k Plan overview

Plan NameUNITED LABORATORIES, INC. EMPLOYEE BENEFITS PLAN
Plan identification number 501

UNITED LABORATORIES, INC. EMPLOYEE BENEFITS PLAN Benefits

401k Plan TypeWelfare Benefit
Plan Features/Benefits
  • Health (other than dental or vision)
  • Life insurance
  • Dental
  • Vision
  • Temporary disability (accident and sickness)
  • Long-term disability cover
  • Other welfare benefit cover

401k Sponsoring company profile

UNITED LABORATORIES, INC. has sponsored the creation of one or more 401k plans.

Company Name:UNITED LABORATORIES, INC.
Employer identification number (EIN):362535769
NAIC Classification:325600

Additional information about UNITED LABORATORIES, INC.

Jurisdiction of Incorporation: Texas Secretary of State
Incorporation Date: 2010-06-24
Company Identification Number: 0801286299
Legal Registered Office Address: 320 37TH AVE

SAINT CHARLES
United States of America (USA)
60174

More information about UNITED LABORATORIES, INC.

Form 5500 Filing Information

Submission information for form 5500 for 401k plan UNITED LABORATORIES, INC. EMPLOYEE BENEFITS PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5012022-04-01
5012021-04-01
5012020-04-01
5012019-04-01
5012018-04-01
5012017-04-01UNITED - TOM LABORATORIES- BANACH
5012016-04-01UNITED - TOM LABORATORIES- BANACH UNITED - TOM LABORATORIES- BANACH2017-11-02
5012015-04-01UNITED - TOM LABORATORIES- BANACH UNITED - TOM LABORATORIES- BANACH2016-11-18
5012014-04-01UNITED - TOM LABORATORIES- BANACH
5012013-04-01UNITED LABORATORIES
5012012-04-01UNITED LABORATORIES
5012011-04-01TOM BANACH TOM BANACH2012-10-30
5012009-04-01TOM BANACH TOM BANACH2010-10-28

Plan Statistics for UNITED LABORATORIES, INC. EMPLOYEE BENEFITS PLAN

401k plan membership statisitcs for UNITED LABORATORIES, INC. EMPLOYEE BENEFITS PLAN

Measure Date Value
2022: UNITED LABORATORIES, INC. EMPLOYEE BENEFITS PLAN 2022 401k membership
Total participants, beginning-of-year2022-04-01183
Total number of active participants reported on line 7a of the Form 55002022-04-01173
Number of retired or separated participants receiving benefits2022-04-010
Number of other retired or separated participants entitled to future benefits2022-04-010
Total of all active and inactive participants2022-04-01173
2021: UNITED LABORATORIES, INC. EMPLOYEE BENEFITS PLAN 2021 401k membership
Total participants, beginning-of-year2021-04-01186
Total number of active participants reported on line 7a of the Form 55002021-04-01183
Number of retired or separated participants receiving benefits2021-04-010
Number of other retired or separated participants entitled to future benefits2021-04-010
Total of all active and inactive participants2021-04-01183
2020: UNITED LABORATORIES, INC. EMPLOYEE BENEFITS PLAN 2020 401k membership
Total participants, beginning-of-year2020-04-01188
Total number of active participants reported on line 7a of the Form 55002020-04-01183
Number of retired or separated participants receiving benefits2020-04-013
Number of other retired or separated participants entitled to future benefits2020-04-010
Total of all active and inactive participants2020-04-01186
2019: UNITED LABORATORIES, INC. EMPLOYEE BENEFITS PLAN 2019 401k membership
Total participants, beginning-of-year2019-04-01183
Total number of active participants reported on line 7a of the Form 55002019-04-01184
Number of retired or separated participants receiving benefits2019-04-014
Number of other retired or separated participants entitled to future benefits2019-04-010
Total of all active and inactive participants2019-04-01188
2018: UNITED LABORATORIES, INC. EMPLOYEE BENEFITS PLAN 2018 401k membership
Total participants, beginning-of-year2018-04-01193
Total number of active participants reported on line 7a of the Form 55002018-04-01180
Number of retired or separated participants receiving benefits2018-04-013
Number of other retired or separated participants entitled to future benefits2018-04-010
Total of all active and inactive participants2018-04-01183
2017: UNITED LABORATORIES, INC. EMPLOYEE BENEFITS PLAN 2017 401k membership
Total participants, beginning-of-year2017-04-01197
Total number of active participants reported on line 7a of the Form 55002017-04-01190
Number of retired or separated participants receiving benefits2017-04-013
Number of other retired or separated participants entitled to future benefits2017-04-010
Total of all active and inactive participants2017-04-01193
2016: UNITED LABORATORIES, INC. EMPLOYEE BENEFITS PLAN 2016 401k membership
Total participants, beginning-of-year2016-04-01206
Total number of active participants reported on line 7a of the Form 55002016-04-01197
Number of retired or separated participants receiving benefits2016-04-010
Number of other retired or separated participants entitled to future benefits2016-04-010
Total of all active and inactive participants2016-04-01197
2015: UNITED LABORATORIES, INC. EMPLOYEE BENEFITS PLAN 2015 401k membership
Total participants, beginning-of-year2015-04-01211
Total number of active participants reported on line 7a of the Form 55002015-04-01205
Number of retired or separated participants receiving benefits2015-04-011
Number of other retired or separated participants entitled to future benefits2015-04-010
Total of all active and inactive participants2015-04-01206
2014: UNITED LABORATORIES, INC. EMPLOYEE BENEFITS PLAN 2014 401k membership
Total participants, beginning-of-year2014-04-01212
Total number of active participants reported on line 7a of the Form 55002014-04-01210
Number of retired or separated participants receiving benefits2014-04-011
Number of other retired or separated participants entitled to future benefits2014-04-010
Total of all active and inactive participants2014-04-01211
2013: UNITED LABORATORIES, INC. EMPLOYEE BENEFITS PLAN 2013 401k membership
Total participants, beginning-of-year2013-04-01224
Total number of active participants reported on line 7a of the Form 55002013-04-01209
Number of retired or separated participants receiving benefits2013-04-013
Number of other retired or separated participants entitled to future benefits2013-04-010
Total of all active and inactive participants2013-04-01212
2012: UNITED LABORATORIES, INC. EMPLOYEE BENEFITS PLAN 2012 401k membership
Total participants, beginning-of-year2012-04-01132
Total number of active participants reported on line 7a of the Form 55002012-04-01130
Number of retired or separated participants receiving benefits2012-04-010
Number of other retired or separated participants entitled to future benefits2012-04-010
Total of all active and inactive participants2012-04-01130
2011: UNITED LABORATORIES, INC. EMPLOYEE BENEFITS PLAN 2011 401k membership
Total participants, beginning-of-year2011-04-01135
Total number of active participants reported on line 7a of the Form 55002011-04-01132
Total of all active and inactive participants2011-04-01132
2009: UNITED LABORATORIES, INC. EMPLOYEE BENEFITS PLAN 2009 401k membership
Total participants, beginning-of-year2009-04-01156
Total number of active participants reported on line 7a of the Form 55002009-04-01136
Total of all active and inactive participants2009-04-01136

Form 5500 Responses for UNITED LABORATORIES, INC. EMPLOYEE BENEFITS PLAN

2022: UNITED LABORATORIES, INC. EMPLOYEE BENEFITS PLAN 2022 form 5500 responses
2022-04-01Type of plan entitySingle employer plan
2022-04-01Submission has been amendedNo
2022-04-01This submission is the final filingNo
2022-04-01This return/report is a short plan year return/report (less than 12 months)No
2022-04-01Plan is a collectively bargained planNo
2022-04-01Plan funding arrangement – InsuranceYes
2022-04-01Plan funding arrangement – General assets of the sponsorYes
2022-04-01Plan benefit arrangement – InsuranceYes
2022-04-01Plan benefit arrangement – General assets of the sponsorYes
2021: UNITED LABORATORIES, INC. EMPLOYEE BENEFITS PLAN 2021 form 5500 responses
2021-04-01Type of plan entitySingle employer plan
2021-04-01Submission has been amendedNo
2021-04-01This submission is the final filingNo
2021-04-01This return/report is a short plan year return/report (less than 12 months)No
2021-04-01Plan is a collectively bargained planNo
2021-04-01Plan funding arrangement – InsuranceYes
2021-04-01Plan funding arrangement – General assets of the sponsorYes
2021-04-01Plan benefit arrangement – InsuranceYes
2021-04-01Plan benefit arrangement – General assets of the sponsorYes
2020: UNITED LABORATORIES, INC. EMPLOYEE BENEFITS PLAN 2020 form 5500 responses
2020-04-01Type of plan entitySingle employer plan
2020-04-01Submission has been amendedNo
2020-04-01This submission is the final filingNo
2020-04-01This return/report is a short plan year return/report (less than 12 months)No
2020-04-01Plan is a collectively bargained planNo
2020-04-01Plan funding arrangement – InsuranceYes
2020-04-01Plan benefit arrangement – InsuranceYes
2019: UNITED LABORATORIES, INC. EMPLOYEE BENEFITS PLAN 2019 form 5500 responses
2019-04-01Type of plan entitySingle employer plan
2019-04-01Submission has been amendedNo
2019-04-01This submission is the final filingNo
2019-04-01This return/report is a short plan year return/report (less than 12 months)No
2019-04-01Plan is a collectively bargained planNo
2019-04-01Plan funding arrangement – InsuranceYes
2019-04-01Plan benefit arrangement – InsuranceYes
2018: UNITED LABORATORIES, INC. EMPLOYEE BENEFITS PLAN 2018 form 5500 responses
2018-04-01Type of plan entitySingle employer plan
2018-04-01Submission has been amendedNo
2018-04-01This submission is the final filingNo
2018-04-01This return/report is a short plan year return/report (less than 12 months)No
2018-04-01Plan is a collectively bargained planNo
2018-04-01Plan funding arrangement – InsuranceYes
2018-04-01Plan benefit arrangement – InsuranceYes
2017: UNITED LABORATORIES, INC. EMPLOYEE BENEFITS PLAN 2017 form 5500 responses
2017-04-01Type of plan entitySingle employer plan
2017-04-01Submission has been amendedNo
2017-04-01This submission is the final filingNo
2017-04-01This return/report is a short plan year return/report (less than 12 months)No
2017-04-01Plan is a collectively bargained planNo
2017-04-01Plan funding arrangement – InsuranceYes
2017-04-01Plan benefit arrangement – InsuranceYes
2016: UNITED LABORATORIES, INC. EMPLOYEE BENEFITS PLAN 2016 form 5500 responses
2016-04-01Type of plan entitySingle employer plan
2016-04-01Submission has been amendedNo
2016-04-01This submission is the final filingNo
2016-04-01This return/report is a short plan year return/report (less than 12 months)No
2016-04-01Plan is a collectively bargained planNo
2016-04-01Plan funding arrangement – InsuranceYes
2016-04-01Plan benefit arrangement – InsuranceYes
2015: UNITED LABORATORIES, INC. EMPLOYEE BENEFITS PLAN 2015 form 5500 responses
2015-04-01Type of plan entitySingle employer plan
2015-04-01Submission has been amendedNo
2015-04-01This submission is the final filingNo
2015-04-01This return/report is a short plan year return/report (less than 12 months)No
2015-04-01Plan is a collectively bargained planNo
2015-04-01Plan funding arrangement – InsuranceYes
2015-04-01Plan benefit arrangement – InsuranceYes
2014: UNITED LABORATORIES, INC. EMPLOYEE BENEFITS PLAN 2014 form 5500 responses
2014-04-01Type of plan entitySingle employer plan
2014-04-01Submission has been amendedNo
2014-04-01This submission is the final filingNo
2014-04-01This return/report is a short plan year return/report (less than 12 months)No
2014-04-01Plan is a collectively bargained planNo
2014-04-01Plan funding arrangement – InsuranceYes
2014-04-01Plan benefit arrangement – InsuranceYes
2013: UNITED LABORATORIES, INC. EMPLOYEE BENEFITS PLAN 2013 form 5500 responses
2013-04-01Type of plan entitySingle employer plan
2013-04-01Submission has been amendedNo
2013-04-01This submission is the final filingNo
2013-04-01This return/report is a short plan year return/report (less than 12 months)No
2013-04-01Plan is a collectively bargained planNo
2013-04-01Plan funding arrangement – InsuranceYes
2013-04-01Plan benefit arrangement – InsuranceYes
2012: UNITED LABORATORIES, INC. EMPLOYEE BENEFITS PLAN 2012 form 5500 responses
2012-04-01Type of plan entitySingle employer plan
2012-04-01Submission has been amendedNo
2012-04-01This submission is the final filingNo
2012-04-01This return/report is a short plan year return/report (less than 12 months)No
2012-04-01Plan is a collectively bargained planNo
2012-04-01Plan funding arrangement – InsuranceYes
2012-04-01Plan funding arrangement – General assets of the sponsorYes
2012-04-01Plan benefit arrangement – InsuranceYes
2012-04-01Plan benefit arrangement – General assets of the sponsorYes
2011: UNITED LABORATORIES, INC. EMPLOYEE BENEFITS PLAN 2011 form 5500 responses
2011-04-01Type of plan entitySingle employer plan
2011-04-01Plan funding arrangement – InsuranceYes
2011-04-01Plan funding arrangement – General assets of the sponsorYes
2011-04-01Plan benefit arrangement – InsuranceYes
2011-04-01Plan benefit arrangement – General assets of the sponsorYes
2009: UNITED LABORATORIES, INC. EMPLOYEE BENEFITS PLAN 2009 form 5500 responses
2009-04-01Type of plan entitySingle employer plan
2009-04-01This submission is the final filingNo
2009-04-01Plan funding arrangement – InsuranceYes
2009-04-01Plan funding arrangement – General assets of the sponsorYes
2009-04-01Plan benefit arrangement – InsuranceYes
2009-04-01Plan benefit arrangement – General assets of the sponsorYes

Insurance Providers Used on plan

UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number0918548
Policy instance 4
Insurance contract or identification number0918548
Number of Individuals Covered185
Insurance policy start date2021-08-01
Insurance policy end date2022-07-31
Total amount of commissions paid to insurance brokerUSD $1,901
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $13,626
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,901
Insurance broker organization code?3
BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )
Policy contract numberP17517/017438
Policy instance 3
Insurance contract or identification numberP17517/017438
Number of Individuals Covered224
Insurance policy start date2021-08-01
Insurance policy end date2022-07-31
Total amount of commissions paid to insurance brokerUSD $81,564
Total amount of fees paid to insurance companyUSD $3,625
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $2,106,560
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $81,564
Amount paid for insurance broker fees3625
Additional information about fees paid to insurance brokerSPECIAL PROGRAMS
Insurance broker organization code?3
DELTA DENTAL OF ILLINOIS (National Association of Insurance Commissioners NAIC id number: 47589 )
Policy contract number20208
Policy instance 2
Insurance contract or identification number20208
Number of Individuals Covered147
Insurance policy start date2021-08-01
Insurance policy end date2022-07-31
Total amount of commissions paid to insurance brokerUSD $5,410
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $108,333
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,410
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberG000ALZR
Policy instance 1
Insurance contract or identification numberG000ALZR
Number of Individuals Covered170
Insurance policy start date2021-08-01
Insurance policy end date2022-07-31
Total amount of commissions paid to insurance brokerUSD $16,126
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH & DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $107,506
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $16,126
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberG000ALZR
Policy instance 4
Insurance contract or identification numberG000ALZR
Number of Individuals Covered167
Insurance policy start date2020-08-01
Insurance policy end date2021-07-31
Total amount of commissions paid to insurance brokerUSD $15,630
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH & DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $104,201
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $15,630
Insurance broker organization code?3
DELTA DENTAL OF ILLINOIS (National Association of Insurance Commissioners NAIC id number: 47589 )
Policy contract number20208
Policy instance 3
Insurance contract or identification number20208
Number of Individuals Covered151
Insurance policy start date2020-08-01
Insurance policy end date2021-07-31
Total amount of commissions paid to insurance brokerUSD $5,798
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $125,341
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,798
Insurance broker organization code?3
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number0918548
Policy instance 2
Insurance contract or identification number0918548
Number of Individuals Covered92
Insurance policy start date2020-08-01
Insurance policy end date2021-07-31
Total amount of commissions paid to insurance brokerUSD $2,115
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $13,145
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,115
Insurance broker organization code?3
BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )
Policy contract numberP17517/017438
Policy instance 1
Insurance contract or identification numberP17517/017438
Number of Individuals Covered237
Insurance policy start date2020-08-01
Insurance policy end date2021-07-31
Total amount of commissions paid to insurance brokerUSD $83,333
Total amount of fees paid to insurance companyUSD $3,475
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $2,176,632
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $83,333
Amount paid for insurance broker fees3475
Additional information about fees paid to insurance brokerSPECIAL PROGRAMS
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberG000ALZR
Policy instance 1
Insurance contract or identification numberG000ALZR
Number of Individuals Covered167
Insurance policy start date2019-08-01
Insurance policy end date2020-07-31
Total amount of commissions paid to insurance brokerUSD $14,816
Total amount of fees paid to insurance companyUSD $4,424
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH & DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $98,775
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $14,816
Amount paid for insurance broker fees4424
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
DELTA DENTAL OF ILLINOIS (National Association of Insurance Commissioners NAIC id number: 47589 )
Policy contract number20208
Policy instance 2
Insurance contract or identification number20208
Number of Individuals Covered155
Insurance policy start date2019-08-01
Insurance policy end date2020-07-31
Total amount of commissions paid to insurance brokerUSD $5,131
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $112,041
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,131
Insurance broker organization code?3
BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )
Policy contract numberP17517/017438
Policy instance 3
Insurance contract or identification numberP17517/017438
Number of Individuals Covered231
Insurance policy start date2019-08-01
Insurance policy end date2020-07-31
Total amount of commissions paid to insurance brokerUSD $81,059
Total amount of fees paid to insurance companyUSD $3,425
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $1,947,084
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $81,059
Amount paid for insurance broker fees3425
Additional information about fees paid to insurance brokerSPECIAL PROGRAMS
Insurance broker organization code?3
DELTA DENTAL OF ILLINOIS (National Association of Insurance Commissioners NAIC id number: 47589 )
Policy contract number20208
Policy instance 3
Insurance contract or identification number20208
Number of Individuals Covered153
Insurance policy start date2018-08-01
Insurance policy end date2019-07-31
Total amount of commissions paid to insurance brokerUSD $5,417
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $107,661
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,417
Insurance broker organization code?3
BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )
Policy contract numberP17517/017438
Policy instance 2
Insurance contract or identification numberP17517/017438
Number of Individuals Covered218
Insurance policy start date2018-08-01
Insurance policy end date2019-07-31
Total amount of commissions paid to insurance brokerUSD $68,363
Total amount of fees paid to insurance companyUSD $3,225
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $1,947,605
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $68,363
Amount paid for insurance broker fees3225
Additional information about fees paid to insurance brokerSPECIAL PROGRAMS
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberG000ALZR
Policy instance 1
Insurance contract or identification numberG000ALZR
Number of Individuals Covered166
Insurance policy start date2018-08-01
Insurance policy end date2019-07-31
Total amount of commissions paid to insurance brokerUSD $14,677
Total amount of fees paid to insurance companyUSD $5,886
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH & DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $97,848
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $14,677
Amount paid for insurance broker fees5886
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberG000ALZR
Policy instance 3
Insurance contract or identification numberG000ALZR
Number of Individuals Covered173
Insurance policy start date2017-08-01
Insurance policy end date2018-07-31
Total amount of commissions paid to insurance brokerUSD $14,910
Total amount of fees paid to insurance companyUSD $5,899
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH & DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $99,402
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $14,910
Amount paid for insurance broker fees5899
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
DELTA DENTAL OF ILLINOIS (National Association of Insurance Commissioners NAIC id number: 47589 )
Policy contract number20208
Policy instance 2
Insurance contract or identification number20208
Number of Individuals Covered148
Insurance policy start date2017-08-01
Insurance policy end date2018-07-31
Total amount of commissions paid to insurance brokerUSD $5,436
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $109,658
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,436
Insurance broker organization code?3
BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )
Policy contract numberP17517/017438
Policy instance 1
Insurance contract or identification numberP17517/017438
Number of Individuals Covered232
Insurance policy start date2017-08-01
Insurance policy end date2018-07-31
Total amount of commissions paid to insurance brokerUSD $71,366
Total amount of fees paid to insurance companyUSD $3,350
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $1,890,783
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $71,366
Amount paid for insurance broker fees3350
Additional information about fees paid to insurance brokerSPECIAL PROGRAMS
Insurance broker organization code?3
DELTA DENTAL OF ILLINOIS (National Association of Insurance Commissioners NAIC id number: 47589 )
Policy contract number20208
Policy instance 3
Insurance contract or identification number20208
Number of Individuals Covered154
Insurance policy start date2016-08-01
Insurance policy end date2017-07-31
Total amount of commissions paid to insurance brokerUSD $6,053
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $111,685
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6,053
Insurance broker organization code?3
Insurance broker nameMESIROW INSURANCE SERVICES, INC.
BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )
Policy contract numberP17517/017438
Policy instance 2
Insurance contract or identification numberP17517/017438
Number of Individuals Covered241
Insurance policy start date2016-08-01
Insurance policy end date2017-07-31
Total amount of commissions paid to insurance brokerUSD $54,484
Total amount of fees paid to insurance companyUSD $3,225
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $1,841,891
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $54,484
Amount paid for insurance broker fees3225
Additional information about fees paid to insurance brokerSPECIAL PROGRAMS
Insurance broker organization code?3
Insurance broker nameMESIROW INSURANCE SERVICES, INC.
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberG000ALZR
Policy instance 1
Insurance contract or identification numberG000ALZR
Number of Individuals Covered171
Insurance policy start date2016-08-01
Insurance policy end date2017-07-31
Total amount of commissions paid to insurance brokerUSD $14,542
Total amount of fees paid to insurance companyUSD $3,493
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH & DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $96,945
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $14,542
Amount paid for insurance broker fees3493
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
Insurance broker nameMESIROW INSURANCE SERVICES, INC.
BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )
Policy contract numberP17510/7
Policy instance 1
Insurance contract or identification numberP17510/7
Number of Individuals Covered248
Insurance policy start date2014-08-01
Insurance policy end date2015-07-31
Total amount of commissions paid to insurance brokerUSD $48,055
Total amount of fees paid to insurance companyUSD $1,523
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 planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $1,615,460
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $48,055
Amount paid for insurance broker fees1523
Additional information about fees paid to insurance brokerSPECIAL PROGRAMS
Insurance broker organization code?3
Insurance broker nameMESIROW INSURANCE SERVICES, INC.
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberG000ALZR
Policy instance 2
Insurance contract or identification numberG000ALZR
Number of Individuals Covered219
Insurance policy start date2014-08-01
Insurance policy end date2015-07-31
Total amount of commissions paid to insurance brokerUSD $14,936
Total amount of fees paid to insurance companyUSD $3,278
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 planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH & DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $99,571
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $14,936
Amount paid for insurance broker fees3278
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
Insurance broker nameMESIROW INSURANCE SERVICES, INC.
DELTA DENTAL OF ILLINOIS (National Association of Insurance Commissioners NAIC id number: 47589 )
Policy contract number20208
Policy instance 3
Insurance contract or identification number20208
Number of Individuals Covered154
Insurance policy start date2014-08-01
Insurance policy end date2015-07-31
Total amount of commissions paid to insurance brokerUSD $5,194
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $104,058
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,194
Insurance broker organization code?3
Insurance broker nameMESIROW INSURANCE SERVICES, INC.
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberG000ALZR
Policy instance 1
Insurance contract or identification numberG000ALZR
Number of Individuals Covered213
Insurance policy start date2013-08-01
Insurance policy end date2014-07-31
Total amount of commissions paid to insurance brokerUSD $13,332
Total amount of fees paid to insurance companyUSD $3,053
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 planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH & DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $88,874
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $13,332
Amount paid for insurance broker fees3053
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
Insurance broker nameMESIROW INSURANCE SERVICES, INC.
DELTA DENTAL OF ILLINOIS (National Association of Insurance Commissioners NAIC id number: 47589 )
Policy contract number20208
Policy instance 2
Insurance contract or identification number20208
Number of Individuals Covered145
Insurance policy start date2013-08-01
Insurance policy end date2014-07-31
Total amount of commissions paid to insurance brokerUSD $4,279
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $93,875
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,279
Insurance broker organization code?3
Insurance broker nameMESIROW INSURANCE SERVICES, INC.
BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )
Policy contract numberP17510/7
Policy instance 3
Insurance contract or identification numberP17510/7
Number of Individuals Covered252
Insurance policy start date2013-08-01
Insurance policy end date2014-07-31
Total amount of commissions paid to insurance brokerUSD $49,965
Total amount of fees paid to insurance companyUSD $1,390
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 planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $1,563,836
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $49,965
Amount paid for insurance broker fees1390
Additional information about fees paid to insurance brokerSPECIAL PROGRAMS
Insurance broker organization code?3
Insurance broker nameMESIROW INSURANCE SERVICES, INC.
BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )
Policy contract numberP17510/7
Policy instance 3
Insurance contract or identification numberP17510/7
Number of Individuals Covered262
Insurance policy start date2012-08-01
Insurance policy end date2013-07-31
Total amount of commissions paid to insurance brokerUSD $44,150
Total amount of fees paid to insurance companyUSD $2,279
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 planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $1,593,472
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $44,150
Amount paid for insurance broker fees2279
Additional information about fees paid to insurance brokerSPECIAL PROGRAMS
Insurance broker organization code?3
Insurance broker nameMESIROW INSURANCE SERVICES, INC.
DELTA DENTAL OF ILLINOIS (National Association of Insurance Commissioners NAIC id number: 47589 )
Policy contract number20208
Policy instance 1
Insurance contract or identification number20208
Number of Individuals Covered144
Insurance policy start date2012-08-01
Insurance policy end date2013-07-31
Total amount of commissions paid to insurance brokerUSD $4,498
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $89,546
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,498
Insurance broker organization code?3
Insurance broker nameMESIROW INSURANCE SERVICES, INC.
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberG000ALZR
Policy instance 2
Insurance contract or identification numberG000ALZR
Number of Individuals Covered223
Insurance policy start date2012-08-01
Insurance policy end date2013-07-31
Total amount of commissions paid to insurance brokerUSD $12,866
Total amount of fees paid to insurance companyUSD $930
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 planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH & DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $85,776
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $12,866
Amount paid for insurance broker fees930
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
Insurance broker nameMESIROW INSURANCE SERVICES, INC.
BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )
Policy contract numberP17510 P17517
Policy instance 1
Insurance contract or identification numberP17510 P17517
Number of Individuals Covered289
Insurance policy start date2011-08-01
Insurance policy end date2012-07-31
Total amount of commissions paid to insurance brokerUSD $48,802
Total amount of fees paid to insurance companyUSD $2,216
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 planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $1,627,391
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $48,802
Amount paid for insurance broker fees2216
Additional information about fees paid to insurance brokerSPECIAL PROGRAMS
Insurance broker organization code?3
Insurance broker nameMESIROW INSURANCE SERVICES
DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 )
Policy contract numberF017713
Policy instance 3
Insurance contract or identification numberF017713
Number of Individuals Covered208
Insurance policy start date2011-08-01
Insurance policy end date2012-07-31
Total amount of commissions paid to insurance brokerUSD $10,186
Total amount of fees paid to insurance companyUSD $2,257
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 planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL, DEATH AND DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $65,483
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $10,186
Amount paid for insurance broker fees2257
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
Insurance broker organization code?3
Insurance broker nameMESIROW INSURANCE SERVICES
DELTA DENTAL OF ILLINOIS (National Association of Insurance Commissioners NAIC id number: 47589 )
Policy contract number20208
Policy instance 2
Insurance contract or identification number20208
Number of Individuals Covered150
Insurance policy start date2011-08-01
Insurance policy end date2012-07-31
Total amount of commissions paid to insurance brokerUSD $4,603
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $84,439
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,603
Insurance broker organization code?3
Insurance broker nameMESIROW INSURANCE SERVICES
DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 )
Policy contract numberF017713
Policy instance 3
Insurance contract or identification numberF017713
Number of Individuals Covered213
Insurance policy start date2010-08-01
Insurance policy end date2011-07-30
Total amount of commissions paid to insurance brokerUSD $8,834
Total amount of fees paid to insurance companyUSD $3,459
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL, DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $58,983
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
DELTA DENTAL OF ILLINOIS (National Association of Insurance Commissioners NAIC id number: 47589 )
Policy contract number20208
Policy instance 2
Insurance contract or identification number20208
Number of Individuals Covered147
Insurance policy start date2010-08-01
Insurance policy end date2011-07-30
Total amount of commissions paid to insurance brokerUSD $4,236
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $84,716
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )
Policy contract numberP17510 P17517
Policy instance 1
Insurance contract or identification numberP17510 P17517
Number of Individuals Covered291
Insurance policy start date2010-08-01
Insurance policy end date2011-07-31
Total amount of commissions paid to insurance brokerUSD $49,940
Total amount of fees paid to insurance companyUSD $2,065
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,627,119
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 numberGLTDOAB7Z
Policy instance 2
Insurance contract or identification numberGLTDOAB7Z
Number of Individuals Covered134
Insurance policy start date2009-08-01
Insurance policy end date2010-08-01
Total amount of commissions paid to insurance brokerUSD $3,033
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Life Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL,DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $20,454
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )
Policy contract numberP17510 P17517
Policy instance 1
Insurance contract or identification numberP17510 P17517
Number of Individuals Covered284
Insurance policy start date2009-08-01
Insurance policy end date2010-07-31
Total amount of commissions paid to insurance brokerUSD $40,893
Total amount of fees paid to insurance companyUSD $2,792
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,393,857
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No

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