FLAVORCHEM CORPORATION has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan FLAVORCHEM CORPORATION WELFARE BENEFIT PLAN
| Measure | Date | Value |
|---|
| 2022: FLAVORCHEM CORPORATION WELFARE BENEFIT PLAN 2022 401k membership |
|---|
| Total participants, beginning-of-year | 2022-01-01 | 360 |
| Total number of active participants reported on line 7a of the Form 5500 | 2022-01-01 | 374 |
| Number of retired or separated participants receiving benefits | 2022-01-01 | 4 |
| Number of other retired or separated participants entitled to future benefits | 2022-01-01 | 0 |
| Total of all active and inactive participants | 2022-01-01 | 378 |
| 2021: FLAVORCHEM CORPORATION WELFARE BENEFIT PLAN 2021 401k membership |
|---|
| Total participants, beginning-of-year | 2021-01-01 | 312 |
| Total number of active participants reported on line 7a of the Form 5500 | 2021-01-01 | 359 |
| Number of retired or separated participants receiving benefits | 2021-01-01 | 1 |
| Number of other retired or separated participants entitled to future benefits | 2021-01-01 | 0 |
| Total of all active and inactive participants | 2021-01-01 | 360 |
| 2020: FLAVORCHEM CORPORATION WELFARE BENEFIT PLAN 2020 401k membership |
|---|
| Total participants, beginning-of-year | 2020-01-01 | 314 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-01-01 | 310 |
| Number of retired or separated participants receiving benefits | 2020-01-01 | 2 |
| Number of other retired or separated participants entitled to future benefits | 2020-01-01 | 0 |
| Total of all active and inactive participants | 2020-01-01 | 312 |
| 2019: FLAVORCHEM CORPORATION WELFARE BENEFIT PLAN 2019 401k membership |
|---|
| Total participants, beginning-of-year | 2019-01-01 | 294 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-01-01 | 314 |
| Number of retired or separated participants receiving benefits | 2019-01-01 | 2 |
| Total of all active and inactive participants | 2019-01-01 | 316 |
| Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits | 2019-01-01 | 1 |
| Total participants | 2019-01-01 | 317 |
| Number of participants with account balances | 2019-01-01 | 0 |
| 2018: FLAVORCHEM CORPORATION WELFARE BENEFIT PLAN 2018 401k membership |
|---|
| Total participants, beginning-of-year | 2018-01-01 | 304 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-01-01 | 294 |
| Number of retired or separated participants receiving benefits | 2018-01-01 | 7 |
| Total of all active and inactive participants | 2018-01-01 | 301 |
| Total participants | 2018-01-01 | 301 |
| 2017: FLAVORCHEM CORPORATION WELFARE BENEFIT PLAN 2017 401k membership |
|---|
| Total participants, beginning-of-year | 2017-01-01 | 0 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-01-01 | 304 |
| Number of retired or separated participants receiving benefits | 2017-01-01 | 3 |
| Number of other retired or separated participants entitled to future benefits | 2017-01-01 | 6 |
| Total of all active and inactive participants | 2017-01-01 | 313 |
| Total participants | 2017-01-01 | 313 |
| 2016: FLAVORCHEM CORPORATION WELFARE BENEFIT PLAN 2016 401k membership |
|---|
| Total participants, beginning-of-year | 2016-01-01 | 225 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-01-01 | 249 |
| Number of other retired or separated participants entitled to future benefits | 2016-01-01 | 5 |
| Total of all active and inactive participants | 2016-01-01 | 254 |
| Total participants | 2016-01-01 | 0 |
| 2015: FLAVORCHEM CORPORATION WELFARE BENEFIT PLAN 2015 401k membership |
|---|
| Total participants, beginning-of-year | 2015-01-01 | 0 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-01-01 | 225 |
| Number of retired or separated participants receiving benefits | 2015-01-01 | 3 |
| Total of all active and inactive participants | 2015-01-01 | 228 |
| Total participants | 2015-01-01 | 0 |
| 2014: FLAVORCHEM CORPORATION WELFARE BENEFIT PLAN 2014 401k membership |
|---|
| Total participants, beginning-of-year | 2014-01-01 | 200 |
| Total number of active participants reported on line 7a of the Form 5500 | 2014-01-01 | 201 |
| Total of all active and inactive participants | 2014-01-01 | 201 |
| Total participants | 2014-01-01 | 0 |
| 2013: FLAVORCHEM CORPORATION WELFARE BENEFIT PLAN 2013 401k membership |
|---|
| Total participants, beginning-of-year | 2013-04-01 | 183 |
| Total number of active participants reported on line 7a of the Form 5500 | 2013-04-01 | 200 |
| Total of all active and inactive participants | 2013-04-01 | 200 |
| Total participants | 2013-04-01 | 0 |
| 2012: FLAVORCHEM CORPORATION WELFARE BENEFIT PLAN 2012 401k membership |
|---|
| Total participants, beginning-of-year | 2012-04-01 | 175 |
| Total number of active participants reported on line 7a of the Form 5500 | 2012-04-01 | 183 |
| Total of all active and inactive participants | 2012-04-01 | 183 |
| Total participants | 2012-04-01 | 183 |
| 2010: FLAVORCHEM CORPORATION WELFARE BENEFIT PLAN 2010 401k membership |
|---|
| Total participants, beginning-of-year | 2010-04-01 | 140 |
| Total number of active participants reported on line 7a of the Form 5500 | 2010-04-01 | 175 |
| Total of all active and inactive participants | 2010-04-01 | 175 |
| Total participants | 2010-04-01 | 175 |
| 2009: FLAVORCHEM CORPORATION WELFARE BENEFIT PLAN 2009 401k membership |
|---|
| Total participants, beginning-of-year | 2009-04-01 | 158 |
| Total number of active participants reported on line 7a of the Form 5500 | 2009-04-01 | 140 |
| Total of all active and inactive participants | 2009-04-01 | 140 |
| Total participants | 2009-04-01 | 140 |
| 2022: FLAVORCHEM CORPORATION WELFARE BENEFIT PLAN 2022 form 5500 responses |
|---|
| 2022-01-01 | Type of plan entity | Single employer plan |
| 2022-01-01 | Submission has been amended | No |
| 2022-01-01 | This submission is the final filing | No |
| 2022-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2022-01-01 | Plan is a collectively bargained plan | No |
| 2022-01-01 | Plan funding arrangement – Insurance | Yes |
| 2022-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2022-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2022-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2021: FLAVORCHEM CORPORATION WELFARE BENEFIT PLAN 2021 form 5500 responses |
|---|
| 2021-01-01 | Type of plan entity | Single employer plan |
| 2021-01-01 | Submission has been amended | No |
| 2021-01-01 | This submission is the final filing | No |
| 2021-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2021-01-01 | Plan is a collectively bargained plan | No |
| 2021-01-01 | Plan funding arrangement – Insurance | Yes |
| 2021-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2021-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2021-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2020: FLAVORCHEM CORPORATION WELFARE BENEFIT PLAN 2020 form 5500 responses |
|---|
| 2020-01-01 | Type of plan entity | Single employer plan |
| 2020-01-01 | Plan funding arrangement – Insurance | Yes |
| 2020-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2020-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2020-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2019: FLAVORCHEM CORPORATION WELFARE BENEFIT PLAN 2019 form 5500 responses |
|---|
| 2019-01-01 | Type of plan entity | Single employer plan |
| 2019-01-01 | Plan funding arrangement – Insurance | Yes |
| 2019-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2019-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2019-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2018: FLAVORCHEM CORPORATION WELFARE BENEFIT PLAN 2018 form 5500 responses |
|---|
| 2018-01-01 | Type of plan entity | Single employer plan |
| 2018-01-01 | Plan funding arrangement – Insurance | Yes |
| 2018-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2018-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2018-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2017: FLAVORCHEM CORPORATION WELFARE BENEFIT PLAN 2017 form 5500 responses |
|---|
| 2017-01-01 | Type of plan entity | Single employer plan |
| 2017-01-01 | Plan funding arrangement – Insurance | Yes |
| 2017-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2017-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2017-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2016: FLAVORCHEM CORPORATION WELFARE BENEFIT PLAN 2016 form 5500 responses |
|---|
| 2016-01-01 | Type of plan entity | Single employer plan |
| 2016-01-01 | Plan funding arrangement – Insurance | Yes |
| 2016-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2016-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2016-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2015: FLAVORCHEM CORPORATION WELFARE BENEFIT PLAN 2015 form 5500 responses |
|---|
| 2015-01-01 | Type of plan entity | Single employer plan |
| 2015-01-01 | Plan funding arrangement – Insurance | Yes |
| 2015-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2015-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2015-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2014: FLAVORCHEM CORPORATION WELFARE BENEFIT PLAN 2014 form 5500 responses |
|---|
| 2014-01-01 | Type of plan entity | Single employer plan |
| 2014-01-01 | Plan funding arrangement – Insurance | Yes |
| 2014-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2014-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2014-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2013: FLAVORCHEM CORPORATION WELFARE BENEFIT PLAN 2013 form 5500 responses |
|---|
| 2013-04-01 | Type of plan entity | Single employer plan |
| 2013-04-01 | This return/report is a short plan year return/report (less than 12 months) | Yes |
| 2013-04-01 | Plan funding arrangement – Insurance | Yes |
| 2013-04-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2013-04-01 | Plan benefit arrangement – Insurance | Yes |
| 2013-04-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2012: FLAVORCHEM CORPORATION WELFARE BENEFIT PLAN 2012 form 5500 responses |
|---|
| 2012-04-01 | Type of plan entity | Single employer plan |
| 2012-04-01 | Submission has been amended | No |
| 2012-04-01 | This submission is the final filing | No |
| 2012-04-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2012-04-01 | Plan is a collectively bargained plan | No |
| 2012-04-01 | Plan funding arrangement – Insurance | Yes |
| 2012-04-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2012-04-01 | Plan benefit arrangement – Insurance | Yes |
| 2012-04-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2010: FLAVORCHEM CORPORATION WELFARE BENEFIT PLAN 2010 form 5500 responses |
|---|
| 2010-04-01 | Type of plan entity | Single employer plan |
| 2010-04-01 | Submission has been amended | No |
| 2010-04-01 | This submission is the final filing | No |
| 2010-04-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2010-04-01 | Plan is a collectively bargained plan | No |
| 2010-04-01 | Plan funding arrangement – Insurance | Yes |
| 2010-04-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2010-04-01 | Plan benefit arrangement – Insurance | Yes |
| 2010-04-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2009: FLAVORCHEM CORPORATION WELFARE BENEFIT PLAN 2009 form 5500 responses |
|---|
| 2009-04-01 | Type of plan entity | Single employer plan |
| 2009-04-01 | Submission has been amended | No |
| 2009-04-01 | This submission is the final filing | No |
| 2009-04-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2009-04-01 | Plan is a collectively bargained plan | No |
| 2009-04-01 | Plan funding arrangement – Insurance | Yes |
| 2009-04-01 | Plan benefit arrangement – Insurance | Yes |
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 12516 ) |
| Policy contract number | 30019091 |
| Policy instance | 3 |
| Insurance contract or identification number | 30019091 | | Number of Individuals Covered | 272 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | 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 $29,166 | | 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 number | 274103 |
| Policy instance | 1 |
| Insurance contract or identification number | 274103 | | Number of Individuals Covered | 653 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $3,130 | | 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 $3,194,664 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 3130 | | Additional information about fees paid to insurance broker | SPECIAL PROGRAMS | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL OF ILLINOIS (National Association of Insurance Commissioners NAIC id number: 47589 ) |
| Policy contract number | 10774 |
| Policy instance | 2 |
| Insurance contract or identification number | 10774 | | Number of Individuals Covered | 324 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | 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 $31,168 | | 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 | VF026878 |
| Policy instance | 9 |
| Insurance contract or identification number | VF026878 | | Number of Individuals Covered | 374 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $116,541 | | 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 | GLUG0BGBX |
| Policy instance | 4 |
| Insurance contract or identification number | GLUG0BGBX | | Number of Individuals Covered | 1 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $279 | | 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 | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $22 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 279 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUC 0BGBX |
| Policy instance | 5 |
| Insurance contract or identification number | GUC 0BGBX | | Number of Individuals Covered | 183 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $2,161 | | 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 | Yes | | 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 $53,614 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 2161 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUDH0BGBX |
| Policy instance | 6 |
| Insurance contract or identification number | GUDH0BGBX | | Number of Individuals Covered | 126 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $4,248 | | Total amount of fees paid to insurance company | USD $1,206 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENT ONLY VOLUNTARY | | 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 $28,322 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,248 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 1206 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUPR0BGBX |
| Policy instance | 7 |
| Insurance contract or identification number | GUPR0BGBX | | Number of Individuals Covered | 148 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $12,714 | | Total amount of fees paid to insurance company | USD $3,618 | | 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 $84,761 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $12,714 | | Amount paid for insurance broker fees | 3618 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GVTL0BGBX |
| Policy instance | 8 |
| Insurance contract or identification number | GVTL0BGBX | | Number of Individuals Covered | 1 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $4,179 | | 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 $29 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 4179 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL OF ILLINOIS (National Association of Insurance Commissioners NAIC id number: 47589 ) |
| Policy contract number | 10774 |
| Policy instance | 2 |
| Insurance contract or identification number | 10774 | | Number of Individuals Covered | 310 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | 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 $30,755 | | 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 number | 274103 |
| Policy instance | 1 |
| Insurance contract or identification number | 274103 | | Number of Individuals Covered | 630 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $2,700 | | 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 $2,910,408 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 2700 | | Additional information about fees paid to insurance broker | SPECIAL PROGRAMS | | Insurance broker organization code? | 3 |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 12516 ) |
| Policy contract number | 30019091 |
| Policy instance | 3 |
| Insurance contract or identification number | 30019091 | | Number of Individuals Covered | 256 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $25,365 | | 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 | GLUG0BGBX |
| Policy instance | 4 |
| Insurance contract or identification number | GLUG0BGBX | | Number of Individuals Covered | 359 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $349 | | 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 | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $6,145 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 349 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUC 0BGBX |
| Policy instance | 5 |
| Insurance contract or identification number | GUC 0BGBX | | Number of Individuals Covered | 177 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $2,497 | | 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 | Yes | | 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 $47,291 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 2497 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUDH0BGBX |
| Policy instance | 6 |
| Insurance contract or identification number | GUDH0BGBX | | Number of Individuals Covered | 125 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $3,983 | | Total amount of fees paid to insurance company | USD $1,504 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENT ONLY VOLUNTARY | | 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 $26,551 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,983 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 1504 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUPR0BGBX |
| Policy instance | 7 |
| Insurance contract or identification number | GUPR0BGBX | | Number of Individuals Covered | 146 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $11,892 | | Total amount of fees paid to insurance company | USD $4,187 | | 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 $79,278 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $11,892 | | Amount paid for insurance broker fees | 4187 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GVTL0BGBX |
| Policy instance | 8 |
| Insurance contract or identification number | GVTL0BGBX | | Number of Individuals Covered | 190 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $5,241 | | 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 $92,197 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 5241 | | 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 | 274103 |
| Policy instance | 1 |
| Insurance contract or identification number | 274103 | | Number of Individuals Covered | 581 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of fees paid to insurance company | USD $3,432 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $2,817,523 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 3432 | | Additional information about fees paid to insurance broker | SPECIAL PROGRAMS | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL OF ILLINOIS (National Association of Insurance Commissioners NAIC id number: 47589 ) |
| Policy contract number | 10774 |
| Policy instance | 2 |
| Insurance contract or identification number | 10774 | | Number of Individuals Covered | 266 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $21,121 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 12516 ) |
| Policy contract number | 30019091 |
| Policy instance | 3 |
| Insurance contract or identification number | 30019091 | | Number of Individuals Covered | 217 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $24,459 | | 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 | GLUG0BGBX |
| Policy instance | 4 |
| Insurance contract or identification number | GLUG0BGBX | | Number of Individuals Covered | 310 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of fees paid to insurance company | USD $199 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $5,818 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 199 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUC 0BGBX |
| Policy instance | 5 |
| Insurance contract or identification number | GUC 0BGBX | | Number of Individuals Covered | 165 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of fees paid to insurance company | USD $1,198 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $41,424 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 1198 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUDH0BGBX |
| Policy instance | 6 |
| Insurance contract or identification number | GUDH0BGBX | | Number of Individuals Covered | 112 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $3,749 | | Total amount of fees paid to insurance company | USD $821 | | Other welfare benefits provided | ACCIDENT ONLY VOLUNTARY | | Welfare Benefit Premiums Paid to Carrier | USD $24,995 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,749 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 821 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUPR0BGBX |
| Policy instance | 7 |
| Insurance contract or identification number | GUPR0BGBX | | Number of Individuals Covered | 132 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $10,431 | | Total amount of fees paid to insurance company | USD $2,273 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $69,538 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $10,431 | | Amount paid for insurance broker fees | 2273 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GVTL0BGBX |
| Policy instance | 8 |
| Insurance contract or identification number | GVTL0BGBX | | Number of Individuals Covered | 183 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of fees paid to insurance company | USD $3,465 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $87,228 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 3465 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GVTL0BGBX |
| Policy instance | 8 |
| Insurance contract or identification number | GVTL0BGBX | | Number of Individuals Covered | 192 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2020-01-01 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $86,360 | | 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 | GUPR0BGBX |
| Policy instance | 7 |
| Insurance contract or identification number | GUPR0BGBX | | Number of Individuals Covered | 138 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2020-01-01 | | Total amount of commissions paid to insurance broker | USD $9,998 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $66,651 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $9,998 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUDH0BGBX |
| Policy instance | 6 |
| Insurance contract or identification number | GUDH0BGBX | | Number of Individuals Covered | 111 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2020-01-01 | | Total amount of commissions paid to insurance broker | USD $3,557 | | Other welfare benefits provided | ACCIDENT ONLY VOLUNTARY | | Welfare Benefit Premiums Paid to Carrier | USD $23,716 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,557 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUC 0BGBX |
| Policy instance | 5 |
| Insurance contract or identification number | GUC 0BGBX | | Number of Individuals Covered | 168 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2020-01-01 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $37,717 | | 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 | GLUG0BGBX |
| Policy instance | 4 |
| Insurance contract or identification number | GLUG0BGBX | | Number of Individuals Covered | 314 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2020-01-01 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $5,728 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 12516 ) |
| Policy contract number | 30019091 |
| Policy instance | 3 |
| Insurance contract or identification number | 30019091 | | Number of Individuals Covered | 228 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $21,122 | | 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 number | 10774 |
| Policy instance | 2 |
| Insurance contract or identification number | 10774 | | Number of Individuals Covered | 273 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $22,208 | | 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 number | 274103 |
| Policy instance | 1 |
| Insurance contract or identification number | 274103 | | Number of Individuals Covered | 605 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of fees paid to insurance company | USD $3,072 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $2,753,183 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 3072 | | Additional information about fees paid to insurance broker | SPECIAL PROGRAMS | | Insurance broker organization code? | 3 |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 12516 ) |
| Policy contract number | 30019091 |
| Policy instance | 4 |
| Insurance contract or identification number | 30019091 | | Number of Individuals Covered | 205 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $19,712 | | 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 number | 10774 |
| Policy instance | 3 |
| Insurance contract or identification number | 10774 | | Number of Individuals Covered | 257 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $19,715 | | 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 | F012690 |
| Policy instance | 2 |
| Insurance contract or identification number | F012690 | | Number of Individuals Covered | 294 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $19,708 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ADD, STD | | Welfare Benefit Premiums Paid to Carrier | USD $166,078 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $9,761 | | Insurance broker organization code? | 3 |
|
| BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 ) |
| Policy contract number | 274103 |
| Policy instance | 1 |
| Insurance contract or identification number | 274103 | | Number of Individuals Covered | 551 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-01-01 | | Total amount of fees paid to insurance company | USD $2,620 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $2,446,939 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 2620 | | Additional information about fees paid to insurance broker | SPECIAL PROGRAMS | | Insurance broker organization code? | 3 |
|
| BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 ) |
| Policy contract number | B/P74103/P75142 |
| Policy instance | 1 |
| Insurance contract or identification number | B/P74103/P75142 | | Number of Individuals Covered | 547 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of fees paid to insurance company | USD $2,130 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $2,193,654 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 2130 | | Additional information about fees paid to insurance broker | SPECIAL PROGRAMS | | Insurance broker organization code? | 3 | | Insurance broker name | THE HORTON GROUP INC. |
|
| DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 ) |
| Policy contract number | F012690 |
| Policy instance | 2 |
| Insurance contract or identification number | F012690 | | Number of Individuals Covered | 304 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of fees paid to insurance company | USD $4,544 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ADD, STD | | Welfare Benefit Premiums Paid to Carrier | USD $140,281 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 4544 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | THE HORTON GROUP INC |
|
| DELTA DENTAL OF ILLINOIS (National Association of Insurance Commissioners NAIC id number: 47589 ) |
| Policy contract number | 10774 |
| Policy instance | 3 |
| Insurance contract or identification number | 10774 | | Number of Individuals Covered | 262 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $20,778 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 12516 ) |
| Policy contract number | 30019091 |
| Policy instance | 4 |
| Insurance contract or identification number | 30019091 | | Number of Individuals Covered | 210 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $18,570 | | 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 number | B/P74103/P75142 |
| Policy instance | 1 |
| Insurance contract or identification number | B/P74103/P75142 | | Number of Individuals Covered | 421 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of fees paid to insurance company | USD $1,800 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,608,193 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 1800 | | Additional information about fees paid to insurance broker | SPECIAL PROGRAMS | | Insurance broker organization code? | 3 | | Insurance broker name | THE HORTON GROUP INC. |
|
| DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 ) |
| Policy contract number | F012690 |
| Policy instance | 2 |
| Insurance contract or identification number | F012690 | | Number of Individuals Covered | 225 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $3,799 | | Total amount of fees paid to insurance company | USD $7,934 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $77,080 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,799 | | Amount paid for insurance broker fees | 4133 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | BOON-CHAPMAN BENEFIT ADMINISTRATORS |
|
| DELTA DENTAL OF ILLINOIS (National Association of Insurance Commissioners NAIC id number: 47589 ) |
| Policy contract number | 10774 |
| Policy instance | 3 |
| Insurance contract or identification number | 10774 | | Number of Individuals Covered | 195 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $14,640 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 12516 ) |
| Policy contract number | 30019091 |
| Policy instance | 4 |
| Insurance contract or identification number | 30019091 | | Number of Individuals Covered | 133 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-03-31 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $3,336 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Insurance broker organization code? | 3 | | Insurance broker name | THE HORTON GROUP INC. |
|
| DELTA DENTAL OF ILLINOIS (National Association of Insurance Commissioners NAIC id number: 47589 ) |
| Policy contract number | 10774 |
| Policy instance | 3 |
| Insurance contract or identification number | 10774 | | Number of Individuals Covered | 181 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $9,862 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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| BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 ) |
| Policy contract number | B/P74103/P75142 |
| Policy instance | 1 |
| Insurance contract or identification number | B/P74103/P75142 | | Number of Individuals Covered | 405 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of fees paid to insurance company | USD $1,790 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,469,196 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 1790 | | Additional information about fees paid to insurance broker | SPECIAL PROGRAMS | | Insurance broker organization code? | 3 | | Insurance broker name | THE HORTON GROUP INC. |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 12516 ) |
| Policy contract number | 30019091 |
| Policy instance | 4 |
| Insurance contract or identification number | 30019091 | | Number of Individuals Covered | 128 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $11,897 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Insurance broker organization code? | 3 | | Insurance broker name | THE HORTON GROUP |
|
| DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 ) |
| Policy contract number | F012690 |
| Policy instance | 2 |
| Insurance contract or identification number | F012690 | | Number of Individuals Covered | 201 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $6,637 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $71,398 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,637 | | Insurance broker organization code? | 3 | | Insurance broker name | THE HORTON GROUP INC |
|
| DELTA DENTAL OF ILLINOIS (National Association of Insurance Commissioners NAIC id number: 47589 ) |
| Policy contract number | 10774 |
| Policy instance | 3 |
| Insurance contract or identification number | 10774 | | Number of Individuals Covered | 183 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $5,739 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $19,660 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,739 | | Insurance broker organization code? | 3 | | Insurance broker name | MID AMERICAN GROUP, INC. |
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| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 217575 |
| Policy instance | 2 |
| Insurance contract or identification number | 217575 | | Number of Individuals Covered | 200 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $5,102 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $47,261 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,102 | | Insurance broker organization code? | 3 | | Insurance broker name | MID AMERICAN GROUP INC |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 12516 ) |
| Policy contract number | 30019091 |
| Policy instance | 4 |
| Insurance contract or identification number | 30019091 | | Number of Individuals Covered | 120 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $416 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $12,034 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $416 | | Insurance broker organization code? | 3 | | Insurance broker name | THE HORTON GROUP |
|
| BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 ) |
| Policy contract number | B/P74103/P75142 |
| Policy instance | 1 |
| Insurance contract or identification number | B/P74103/P75142 | | Number of Individuals Covered | 400 | | Insurance policy start date | 2013-04-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $45,191 | | Total amount of fees paid to insurance company | USD $2,346 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,038,007 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $45,191 | | Amount paid for insurance broker fees | 2346 | | Additional information about fees paid to insurance broker | SPECIAL PROGRAMS | | Insurance broker organization code? | 3 | | Insurance broker name | MIDAMERICAN GROUP, INC. |
|
| DELTA DENTAL OF ILLINOIS (National Association of Insurance Commissioners NAIC id number: 47589 ) |
| Policy contract number | 10774 |
| Policy instance | 4 |
| Insurance contract or identification number | 10774 | | Number of Individuals Covered | 167 | | Insurance policy start date | 2012-04-01 | | Insurance policy end date | 2013-03-31 | | Total amount of commissions paid to insurance broker | USD $8,032 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $22,635 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,032 | | Insurance broker organization code? | 3 | | Insurance broker name | MID AMERICAN GROUP, INC. |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 217575 |
| Policy instance | 3 |
| Insurance contract or identification number | 217575 | | Number of Individuals Covered | 183 | | Insurance policy start date | 2012-04-01 | | Insurance policy end date | 2013-03-31 | | Total amount of commissions paid to insurance broker | USD $12,091 | | Total amount of fees paid to insurance company | USD $6,255 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $60,465 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $12,091 | | Amount paid for insurance broker fees | 6255 | | Additional information about fees paid to insurance broker | BONUS | | Insurance broker organization code? | 3 | | Insurance broker name | MID AMERICAN GROUP, INC. |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 12516 ) |
| Policy contract number | 30019091 |
| Policy instance | 2 |
| Insurance contract or identification number | 30019091 | | Number of Individuals Covered | 108 | | Insurance policy start date | 2012-04-01 | | Insurance policy end date | 2013-03-31 | | Total amount of commissions paid to insurance broker | USD $1,158 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $11,582 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,158 | | Insurance broker organization code? | 3 | | Insurance broker name | MID AMERICAN GROUP, INC. |
|
| BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 ) |
| Policy contract number | B/P74103/P75142 |
| Policy instance | 1 |
| Insurance contract or identification number | B/P74103/P75142 | | Number of Individuals Covered | 369 | | Insurance policy start date | 2012-04-01 | | Insurance policy end date | 2013-03-31 | | Total amount of commissions paid to insurance broker | USD $46,701 | | Total amount of fees paid to insurance company | USD $2,378 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,284,284 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $46,701 | | Amount paid for insurance broker fees | 2378 | | Additional information about fees paid to insurance broker | SPECIAL PROGRAMS | | Insurance broker organization code? | 3 | | Insurance broker name | MID AMERICAN GROUP, INC. |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 12516 ) |
| Policy contract number | 30019091 |
| Policy instance | 4 |
| Insurance contract or identification number | 30019091 | | Number of Individuals Covered | 106 | | Insurance policy start date | 2010-04-01 | | Insurance policy end date | 2011-03-31 | | Total amount of commissions paid to insurance broker | USD $1,037 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $10,370 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
| Policy contract number | 865571G |
| Policy instance | 3 |
| Insurance contract or identification number | 865571G | | Number of Individuals Covered | 175 | | Insurance policy start date | 2010-04-01 | | Insurance policy end date | 2011-03-31 | | Total amount of commissions paid to insurance broker | USD $15,326 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $76,291 | | 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 number | 10774 |
| Policy instance | 2 |
| Insurance contract or identification number | 10774 | | Number of Individuals Covered | 20 | | Insurance policy start date | 2010-04-01 | | Insurance policy end date | 2011-03-31 | | Total amount of commissions paid to insurance broker | USD $561 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $7,484 | | 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 number | B/P74103,P75142 |
| Policy instance | 1 |
| Insurance contract or identification number | B/P74103,P75142 | | Number of Individuals Covered | 345 | | Insurance policy start date | 2010-04-01 | | Insurance policy end date | 2011-03-31 | | Total amount of commissions paid to insurance broker | USD $45,396 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,101,093 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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