THE GOOD SAMARITAN HOME OF QUINCY has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan GOOD SAMARITAN HOME OF QUINCY IL WELFARE BENEFIT PLAN
401k plan membership statisitcs for GOOD SAMARITAN HOME OF QUINCY IL WELFARE BENEFIT PLAN
| Measure | Date | Value |
|---|
| 2022: GOOD SAMARITAN HOME OF QUINCY IL WELFARE BENEFIT PLAN 2022 401k membership |
|---|
| Total participants, beginning-of-year | 2022-01-01 | 115 |
| Total number of active participants reported on line 7a of the Form 5500 | 2022-01-01 | 35 |
| Number of retired or separated participants receiving benefits | 2022-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2022-01-01 | 0 |
| Total of all active and inactive participants | 2022-01-01 | 35 |
| 2021: GOOD SAMARITAN HOME OF QUINCY IL WELFARE BENEFIT PLAN 2021 401k membership |
|---|
| Total participants, beginning-of-year | 2021-01-01 | 199 |
| Total number of active participants reported on line 7a of the Form 5500 | 2021-01-01 | 115 |
| Number of retired or separated participants receiving benefits | 2021-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2021-01-01 | 0 |
| Total of all active and inactive participants | 2021-01-01 | 115 |
| 2020: GOOD SAMARITAN HOME OF QUINCY IL WELFARE BENEFIT PLAN 2020 401k membership |
|---|
| Total participants, beginning-of-year | 2020-01-01 | 210 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-01-01 | 199 |
| Number of retired or separated participants receiving benefits | 2020-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2020-01-01 | 0 |
| Total of all active and inactive participants | 2020-01-01 | 199 |
| 2019: GOOD SAMARITAN HOME OF QUINCY IL WELFARE BENEFIT PLAN 2019 401k membership |
|---|
| Total participants, beginning-of-year | 2019-01-01 | 215 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-01-01 | 209 |
| Number of retired or separated participants receiving benefits | 2019-01-01 | 1 |
| Number of other retired or separated participants entitled to future benefits | 2019-01-01 | 0 |
| Total of all active and inactive participants | 2019-01-01 | 210 |
| 2018: GOOD SAMARITAN HOME OF QUINCY IL WELFARE BENEFIT PLAN 2018 401k membership |
|---|
| Total participants, beginning-of-year | 2018-01-01 | 138 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-01-01 | 129 |
| Number of retired or separated participants receiving benefits | 2018-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2018-01-01 | 0 |
| Total of all active and inactive participants | 2018-01-01 | 129 |
| 2017: GOOD SAMARITAN HOME OF QUINCY IL WELFARE BENEFIT PLAN 2017 401k membership |
|---|
| Total participants, beginning-of-year | 2017-03-01 | 140 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-03-01 | 134 |
| Number of retired or separated participants receiving benefits | 2017-03-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2017-03-01 | 0 |
| Total of all active and inactive participants | 2017-03-01 | 134 |
| 2016: GOOD SAMARITAN HOME OF QUINCY IL WELFARE BENEFIT PLAN 2016 401k membership |
|---|
| Total participants, beginning-of-year | 2016-03-01 | 135 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-03-01 | 136 |
| Number of retired or separated participants receiving benefits | 2016-03-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2016-03-01 | 0 |
| Total of all active and inactive participants | 2016-03-01 | 136 |
| 2015: GOOD SAMARITAN HOME OF QUINCY IL WELFARE BENEFIT PLAN 2015 401k membership |
|---|
| Total participants, beginning-of-year | 2015-03-01 | 142 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-03-01 | 131 |
| Number of retired or separated participants receiving benefits | 2015-03-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2015-03-01 | 0 |
| Total of all active and inactive participants | 2015-03-01 | 131 |
| 2014: GOOD SAMARITAN HOME OF QUINCY IL WELFARE BENEFIT PLAN 2014 401k membership |
|---|
| Total participants, beginning-of-year | 2014-03-01 | 132 |
| Total number of active participants reported on line 7a of the Form 5500 | 2014-03-01 | 144 |
| Number of retired or separated participants receiving benefits | 2014-03-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2014-03-01 | 0 |
| Total of all active and inactive participants | 2014-03-01 | 144 |
| 2013: GOOD SAMARITAN HOME OF QUINCY IL WELFARE BENEFIT PLAN 2013 401k membership |
|---|
| Total participants, beginning-of-year | 2013-03-01 | 154 |
| Total number of active participants reported on line 7a of the Form 5500 | 2013-03-01 | 139 |
| Number of retired or separated participants receiving benefits | 2013-03-01 | 1 |
| Total of all active and inactive participants | 2013-03-01 | 140 |
| 2012: GOOD SAMARITAN HOME OF QUINCY IL WELFARE BENEFIT PLAN 2012 401k membership |
|---|
| Total participants, beginning-of-year | 2012-03-01 | 157 |
| Total number of active participants reported on line 7a of the Form 5500 | 2012-03-01 | 153 |
| Number of retired or separated participants receiving benefits | 2012-03-01 | 1 |
| Total of all active and inactive participants | 2012-03-01 | 154 |
| 2011: GOOD SAMARITAN HOME OF QUINCY IL WELFARE BENEFIT PLAN 2011 401k membership |
|---|
| Total participants, beginning-of-year | 2011-03-01 | 147 |
| Total number of active participants reported on line 7a of the Form 5500 | 2011-03-01 | 155 |
| Number of retired or separated participants receiving benefits | 2011-03-01 | 2 |
| Total of all active and inactive participants | 2011-03-01 | 157 |
| Total participants | 2011-03-01 | 157 |
| 2010: GOOD SAMARITAN HOME OF QUINCY IL WELFARE BENEFIT PLAN 2010 401k membership |
|---|
| Total participants, beginning-of-year | 2010-03-01 | 140 |
| Total number of active participants reported on line 7a of the Form 5500 | 2010-03-01 | 145 |
| Number of retired or separated participants receiving benefits | 2010-03-01 | 2 |
| Total of all active and inactive participants | 2010-03-01 | 147 |
| Total participants | 2010-03-01 | 147 |
| 2009: GOOD SAMARITAN HOME OF QUINCY IL WELFARE BENEFIT PLAN 2009 401k membership |
|---|
| Total participants, beginning-of-year | 2009-03-01 | 131 |
| Total number of active participants reported on line 7a of the Form 5500 | 2009-03-01 | 140 |
| Number of retired or separated participants receiving benefits | 2009-03-01 | 0 |
| Total of all active and inactive participants | 2009-03-01 | 140 |
| Total participants | 2009-03-01 | 140 |
| 2008: GOOD SAMARITAN HOME OF QUINCY IL WELFARE BENEFIT PLAN 2008 401k membership |
|---|
| Total participants, beginning-of-year | 2008-03-01 | 133 |
| Total number of active participants reported on line 7a of the Form 5500 | 2008-03-01 | 131 |
| Number of retired or separated participants receiving benefits | 2008-03-01 | 0 |
| Total of all active and inactive participants | 2008-03-01 | 131 |
| Total participants | 2008-03-01 | 131 |
| 2022: GOOD SAMARITAN HOME OF QUINCY IL 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: GOOD SAMARITAN HOME OF QUINCY IL 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: GOOD SAMARITAN HOME OF QUINCY IL WELFARE BENEFIT PLAN 2020 form 5500 responses |
|---|
| 2020-01-01 | Type of plan entity | Single employer plan |
| 2020-01-01 | Submission has been amended | No |
| 2020-01-01 | This submission is the final filing | No |
| 2020-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2020-01-01 | Plan is a collectively bargained plan | No |
| 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: GOOD SAMARITAN HOME OF QUINCY IL WELFARE BENEFIT PLAN 2019 form 5500 responses |
|---|
| 2019-01-01 | Type of plan entity | Single employer plan |
| 2019-01-01 | Submission has been amended | No |
| 2019-01-01 | This submission is the final filing | No |
| 2019-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2019-01-01 | Plan is a collectively bargained plan | No |
| 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: GOOD SAMARITAN HOME OF QUINCY IL WELFARE BENEFIT PLAN 2018 form 5500 responses |
|---|
| 2018-01-01 | Type of plan entity | Single employer plan |
| 2018-01-01 | Submission has been amended | No |
| 2018-01-01 | This submission is the final filing | No |
| 2018-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2018-01-01 | Plan is a collectively bargained plan | No |
| 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: GOOD SAMARITAN HOME OF QUINCY IL WELFARE BENEFIT PLAN 2017 form 5500 responses |
|---|
| 2017-03-01 | Type of plan entity | Single employer plan |
| 2017-03-01 | Submission has been amended | No |
| 2017-03-01 | This submission is the final filing | No |
| 2017-03-01 | This return/report is a short plan year return/report (less than 12 months) | Yes |
| 2017-03-01 | Plan is a collectively bargained plan | No |
| 2017-03-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2017-03-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2016: GOOD SAMARITAN HOME OF QUINCY IL WELFARE BENEFIT PLAN 2016 form 5500 responses |
|---|
| 2016-03-01 | Type of plan entity | Single employer plan |
| 2016-03-01 | Submission has been amended | No |
| 2016-03-01 | This submission is the final filing | No |
| 2016-03-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2016-03-01 | Plan is a collectively bargained plan | No |
| 2016-03-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2016-03-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2015: GOOD SAMARITAN HOME OF QUINCY IL WELFARE BENEFIT PLAN 2015 form 5500 responses |
|---|
| 2015-03-01 | Type of plan entity | Single employer plan |
| 2015-03-01 | Submission has been amended | No |
| 2015-03-01 | This submission is the final filing | No |
| 2015-03-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2015-03-01 | Plan is a collectively bargained plan | No |
| 2015-03-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2015-03-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2014: GOOD SAMARITAN HOME OF QUINCY IL WELFARE BENEFIT PLAN 2014 form 5500 responses |
|---|
| 2014-03-01 | Type of plan entity | Single employer plan |
| 2014-03-01 | Submission has been amended | No |
| 2014-03-01 | This submission is the final filing | No |
| 2014-03-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2014-03-01 | Plan is a collectively bargained plan | No |
| 2014-03-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2014-03-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2013: GOOD SAMARITAN HOME OF QUINCY IL WELFARE BENEFIT PLAN 2013 form 5500 responses |
|---|
| 2013-03-01 | Type of plan entity | Single employer plan |
| 2013-03-01 | Submission has been amended | No |
| 2013-03-01 | This submission is the final filing | No |
| 2013-03-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2013-03-01 | Plan is a collectively bargained plan | No |
| 2013-03-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2013-03-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2012: GOOD SAMARITAN HOME OF QUINCY IL WELFARE BENEFIT PLAN 2012 form 5500 responses |
|---|
| 2012-03-01 | Type of plan entity | Single employer plan |
| 2012-03-01 | Submission has been amended | No |
| 2012-03-01 | This submission is the final filing | No |
| 2012-03-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2012-03-01 | Plan is a collectively bargained plan | No |
| 2012-03-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2012-03-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2011: GOOD SAMARITAN HOME OF QUINCY IL WELFARE BENEFIT PLAN 2011 form 5500 responses |
|---|
| 2011-03-01 | Type of plan entity | Single employer plan |
| 2011-03-01 | Submission has been amended | No |
| 2011-03-01 | This submission is the final filing | No |
| 2011-03-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2011-03-01 | Plan is a collectively bargained plan | No |
| 2011-03-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2011-03-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2010: GOOD SAMARITAN HOME OF QUINCY IL WELFARE BENEFIT PLAN 2010 form 5500 responses |
|---|
| 2010-03-01 | Type of plan entity | Single employer plan |
| 2010-03-01 | Submission has been amended | No |
| 2010-03-01 | This submission is the final filing | No |
| 2010-03-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2010-03-01 | Plan is a collectively bargained plan | No |
| 2010-03-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2010-03-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2009: GOOD SAMARITAN HOME OF QUINCY IL WELFARE BENEFIT PLAN 2009 form 5500 responses |
|---|
| 2009-03-01 | Type of plan entity | Single employer plan |
| 2009-03-01 | Submission has been amended | No |
| 2009-03-01 | This submission is the final filing | No |
| 2009-03-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2009-03-01 | Plan is a collectively bargained plan | No |
| 2009-03-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2009-03-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2008: GOOD SAMARITAN HOME OF QUINCY IL WELFARE BENEFIT PLAN 2008 form 5500 responses |
|---|
| 2008-03-01 | Type of plan entity | Single employer plan |
| 2008-03-01 | Submission has been amended | No |
| 2008-03-01 | This submission is the final filing | No |
| 2008-03-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2008-03-01 | Plan is a collectively bargained plan | No |
| 2008-03-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2008-03-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 ) |
| Policy contract number | 0008460648 |
| Policy instance | 2 |
| Insurance contract or identification number | 0008460648 | | Number of Individuals Covered | 35 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $412 | | Total amount of fees paid to insurance company | USD $0 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $8,224 | | 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 | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 496899 |
| Policy instance | 1 |
| Insurance contract or identification number | 496899 | | Number of Individuals Covered | 14 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $890 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $6,168 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $890 | | Insurance broker organization code? | 3 |
|
| PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 ) |
| Policy contract number | 0008460648 |
| Policy instance | 2 |
| Insurance contract or identification number | 0008460648 | | Number of Individuals Covered | 115 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $4,970 | | Total amount of fees paid to insurance company | USD $0 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $32,430 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $40 | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 496899 |
| Policy instance | 1 |
| Insurance contract or identification number | 496899 | | Number of Individuals Covered | 15 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $885 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $6,137 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $885 | | Insurance broker organization code? | 3 |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 12516 ) |
| Policy contract number | 30013146 |
| Policy instance | 4 |
| Insurance contract or identification number | 30013146 | | Number of Individuals Covered | 0 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $201 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $2,958 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $201 | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 575845 |
| Policy instance | 3 |
| Insurance contract or identification number | 575845 | | Number of Individuals Covered | 199 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $349 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $2,906 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $349 | | Insurance broker organization code? | 3 |
|
| PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 ) |
| Policy contract number | 0008460648 |
| Policy instance | 2 |
| Insurance contract or identification number | 0008460648 | | Number of Individuals Covered | 120 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $3,238 | | Total amount of fees paid to insurance company | USD $0 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $30,449 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $48 | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 496899 |
| Policy instance | 1 |
| Insurance contract or identification number | 496899 | | Number of Individuals Covered | 15 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $651 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $4,510 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $651 | | Insurance broker organization code? | 3 |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 12516 ) |
| Policy contract number | 30013146 |
| Policy instance | 4 |
| Insurance contract or identification number | 30013146 | | Number of Individuals Covered | 117 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $912 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $16,899 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $912 | | Insurance broker organization code? | 3 |
|
| PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 ) |
| Policy contract number | 0008460648 |
| Policy instance | 3 |
| Insurance contract or identification number | 0008460648 | | Number of Individuals Covered | 139 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $3,941 | | Total amount of fees paid to insurance company | USD $0 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $36,639 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,886 | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 496899 |
| Policy instance | 2 |
| Insurance contract or identification number | 496899 | | Number of Individuals Covered | 10 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $572 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | A D & D | | Welfare Benefit Premiums Paid to Carrier | USD $3,588 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $572 | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 575845 |
| Policy instance | 1 |
| Insurance contract or identification number | 575845 | | Number of Individuals Covered | 196 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $3,080 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | A D & D | | Welfare Benefit Premiums Paid to Carrier | USD $25,664 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,080 | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 496899 |
| Policy instance | 4 |
| Insurance contract or identification number | 496899 | | Number of Individuals Covered | 15 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $614 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | A D & D | | Welfare Benefit Premiums Paid to Carrier | USD $4,642 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $614 | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 575845 |
| Policy instance | 3 |
| Insurance contract or identification number | 575845 | | Number of Individuals Covered | 240 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $1,442 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | A D & D | | Welfare Benefit Premiums Paid to Carrier | USD $24,473 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,442 | | Insurance broker organization code? | 3 |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 12516 ) |
| Policy contract number | 30013146 |
| Policy instance | 2 |
| Insurance contract or identification number | 30013146 | | Number of Individuals Covered | 127 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $1,025 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $17,569 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,025 | | Insurance broker organization code? | 3 |
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| PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 ) |
| Policy contract number | 0008460648 |
| Policy instance | 1 |
| Insurance contract or identification number | 0008460648 | | Number of Individuals Covered | 168 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $4,907 | | Total amount of fees paid to insurance company | USD $0 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $40,821 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,847 | | Insurance broker organization code? | 3 |
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