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UNIVERSITY LIGGETT SCHOOL WELFARE BENEFIT PLAN 401k Plan overview

Plan NameUNIVERSITY LIGGETT SCHOOL WELFARE BENEFIT PLAN
Plan identification number 501

UNIVERSITY LIGGETT SCHOOL WELFARE BENEFIT PLAN Benefits

401k Plan TypeWelfare Benefit
Plan Features/Benefits
  • Health (other than dental or vision)
  • Life insurance
  • Dental
  • Vision
  • Temporary disability (accident and sickness)
  • Long-term disability cover
  • Death benefits (include travel accident but not life insurance)

401k Sponsoring company profile

UNIVERSITY LIGGETT SCHOOL has sponsored the creation of one or more 401k plans.

Company Name:UNIVERSITY LIGGETT SCHOOL
Employer identification number (EIN):381360536
NAIC Classification:611000

Additional information about UNIVERSITY LIGGETT SCHOOL

Jurisdiction of Incorporation: Michigan Department of Licensing & Regulatory Affairs
Incorporation Date:
Company Identification Number: 740168

More information about UNIVERSITY LIGGETT SCHOOL

Form 5500 Filing Information

Submission information for form 5500 for 401k plan UNIVERSITY LIGGETT SCHOOL WELFARE BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5012021-09-01ANCA MITCHELL2023-05-30
5012020-09-01
5012019-09-01
5012018-09-01
5012017-09-01
5012016-09-01ANCA MITCHELL
5012015-09-01ANCA MITCHELL
5012014-09-01JONATHAN NEVILLE
5012013-09-01JONATHAN NEVILLE
5012012-09-01JONATHAN NEVILLE
5012011-09-01JONATHAN NEVILLE
5012010-09-01JONATHAN NEVILLE
5012009-09-01DAVID G. BORING

Plan Statistics for UNIVERSITY LIGGETT SCHOOL WELFARE BENEFIT PLAN

401k plan membership statisitcs for UNIVERSITY LIGGETT SCHOOL WELFARE BENEFIT PLAN

Measure Date Value
2021: UNIVERSITY LIGGETT SCHOOL WELFARE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year2021-09-01124
Total number of active participants reported on line 7a of the Form 55002021-09-01194
Number of retired or separated participants receiving benefits2021-09-010
Number of other retired or separated participants entitled to future benefits2021-09-010
Total of all active and inactive participants2021-09-01194
Number of employers contributing to the scheme2021-09-010
2020: UNIVERSITY LIGGETT SCHOOL WELFARE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year2020-09-01122
Total number of active participants reported on line 7a of the Form 55002020-09-01124
Number of retired or separated participants receiving benefits2020-09-010
Number of other retired or separated participants entitled to future benefits2020-09-010
Total of all active and inactive participants2020-09-01124
2019: UNIVERSITY LIGGETT SCHOOL WELFARE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year2019-09-01124
Total number of active participants reported on line 7a of the Form 55002019-09-01122
Number of retired or separated participants receiving benefits2019-09-010
Number of other retired or separated participants entitled to future benefits2019-09-010
Total of all active and inactive participants2019-09-01122
2018: UNIVERSITY LIGGETT SCHOOL WELFARE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year2018-09-01116
Total number of active participants reported on line 7a of the Form 55002018-09-01124
Number of retired or separated participants receiving benefits2018-09-010
Number of other retired or separated participants entitled to future benefits2018-09-010
Total of all active and inactive participants2018-09-01124
2017: UNIVERSITY LIGGETT SCHOOL WELFARE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year2017-09-01118
Total number of active participants reported on line 7a of the Form 55002017-09-01116
Number of retired or separated participants receiving benefits2017-09-010
Number of other retired or separated participants entitled to future benefits2017-09-010
Total of all active and inactive participants2017-09-01116
2016: UNIVERSITY LIGGETT SCHOOL WELFARE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year2016-09-01119
Total number of active participants reported on line 7a of the Form 55002016-09-01118
Number of retired or separated participants receiving benefits2016-09-010
Number of other retired or separated participants entitled to future benefits2016-09-010
Total of all active and inactive participants2016-09-01118
2015: UNIVERSITY LIGGETT SCHOOL WELFARE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year2015-09-01114
Total number of active participants reported on line 7a of the Form 55002015-09-01119
Number of retired or separated participants receiving benefits2015-09-010
Number of other retired or separated participants entitled to future benefits2015-09-010
Total of all active and inactive participants2015-09-01119
2014: UNIVERSITY LIGGETT SCHOOL WELFARE BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year2014-09-01122
Total number of active participants reported on line 7a of the Form 55002014-09-01114
Number of retired or separated participants receiving benefits2014-09-010
Number of other retired or separated participants entitled to future benefits2014-09-010
Total of all active and inactive participants2014-09-01114
2013: UNIVERSITY LIGGETT SCHOOL WELFARE BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year2013-09-01115
Total number of active participants reported on line 7a of the Form 55002013-09-01122
Number of retired or separated participants receiving benefits2013-09-010
Number of other retired or separated participants entitled to future benefits2013-09-010
Total of all active and inactive participants2013-09-01122
2012: UNIVERSITY LIGGETT SCHOOL WELFARE BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year2012-09-01108
Total number of active participants reported on line 7a of the Form 55002012-09-01115
Number of retired or separated participants receiving benefits2012-09-010
Number of other retired or separated participants entitled to future benefits2012-09-010
Total of all active and inactive participants2012-09-01115
2011: UNIVERSITY LIGGETT SCHOOL WELFARE BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year2011-09-01110
Total number of active participants reported on line 7a of the Form 55002011-09-01108
Number of retired or separated participants receiving benefits2011-09-012
Number of other retired or separated participants entitled to future benefits2011-09-010
Total of all active and inactive participants2011-09-01110
2010: UNIVERSITY LIGGETT SCHOOL WELFARE BENEFIT PLAN 2010 401k membership
Total participants, beginning-of-year2010-09-01104
Total number of active participants reported on line 7a of the Form 55002010-09-01101
Number of retired or separated participants receiving benefits2010-09-019
Number of other retired or separated participants entitled to future benefits2010-09-010
Total of all active and inactive participants2010-09-01110
2009: UNIVERSITY LIGGETT SCHOOL WELFARE BENEFIT PLAN 2009 401k membership
Total participants, beginning-of-year2009-09-01115
Total number of active participants reported on line 7a of the Form 55002009-09-01104
Number of retired or separated participants receiving benefits2009-09-010
Number of other retired or separated participants entitled to future benefits2009-09-010
Total of all active and inactive participants2009-09-01104

Financial Data on UNIVERSITY LIGGETT SCHOOL WELFARE BENEFIT PLAN

Measure Date Value
2021 : UNIVERSITY LIGGETT SCHOOL WELFARE BENEFIT PLAN 2021 401k financial data
Transfers to/from the plan2021-08-31$-3,400
Total income from all sources2021-08-31$22,455
Expenses. Total of all expenses incurred2021-08-31$19,055
Benefits paid (including direct rollovers)2021-08-31$19,055
Total plan assets at end of year2021-08-31$7,884
Total plan assets at beginning of year2021-08-31$7,884
Value of fidelity bond covering the plan2021-08-31$500,000
Total contributions received or receivable from participants2021-08-31$22,455
Net income (gross income less expenses)2021-08-31$3,400
Net plan assets at end of year (total assets less liabilities)2021-08-31$7,884
Net plan assets at beginning of year (total assets less liabilities)2021-08-31$7,884
2020 : UNIVERSITY LIGGETT SCHOOL WELFARE BENEFIT PLAN 2020 401k financial data
Transfers to/from the plan2020-08-31$-1,839
Total income from all sources2020-08-31$30,149
Expenses. Total of all expenses incurred2020-08-31$28,310
Benefits paid (including direct rollovers)2020-08-31$28,310
Total plan assets at end of year2020-08-31$7,851
Total plan assets at beginning of year2020-08-31$7,851
Value of fidelity bond covering the plan2020-08-31$500,000
Total contributions received or receivable from participants2020-08-31$30,149
Net income (gross income less expenses)2020-08-31$1,839
Net plan assets at end of year (total assets less liabilities)2020-08-31$7,851
Net plan assets at beginning of year (total assets less liabilities)2020-08-31$7,851
2019 : UNIVERSITY LIGGETT SCHOOL WELFARE BENEFIT PLAN 2019 401k financial data
Transfers to/from the plan2019-08-31$-2,611
Total income from all sources2019-08-31$32,669
Expenses. Total of all expenses incurred2019-08-31$30,058
Benefits paid (including direct rollovers)2019-08-31$30,058
Total plan assets at end of year2019-08-31$7,936
Total plan assets at beginning of year2019-08-31$7,936
Total contributions received or receivable from participants2019-08-31$32,669
Net income (gross income less expenses)2019-08-31$2,611
Net plan assets at end of year (total assets less liabilities)2019-08-31$7,936
Net plan assets at beginning of year (total assets less liabilities)2019-08-31$7,936
2017 : UNIVERSITY LIGGETT SCHOOL WELFARE BENEFIT PLAN 2017 401k financial data
Transfers to/from the plan2017-08-31$637
Total income from all sources2017-08-31$42,914
Expenses. Total of all expenses incurred2017-08-31$43,551
Benefits paid (including direct rollovers)2017-08-31$43,551
Total plan assets at end of year2017-08-31$7,901
Total plan assets at beginning of year2017-08-31$7,901
Total contributions received or receivable from participants2017-08-31$42,914
Net income (gross income less expenses)2017-08-31$-637
Net plan assets at end of year (total assets less liabilities)2017-08-31$7,901
Net plan assets at beginning of year (total assets less liabilities)2017-08-31$7,901
2016 : UNIVERSITY LIGGETT SCHOOL WELFARE BENEFIT PLAN 2016 401k financial data
Transfers to/from the plan2016-08-31$-7,456
Total income from all sources2016-08-31$47,786
Expenses. Total of all expenses incurred2016-08-31$40,330
Benefits paid (including direct rollovers)2016-08-31$40,330
Total plan assets at end of year2016-08-31$2,533
Total plan assets at beginning of year2016-08-31$2,533
Total contributions received or receivable from participants2016-08-31$47,786
Net income (gross income less expenses)2016-08-31$7,456
Net plan assets at end of year (total assets less liabilities)2016-08-31$2,533
Net plan assets at beginning of year (total assets less liabilities)2016-08-31$2,533
2015 : UNIVERSITY LIGGETT SCHOOL WELFARE BENEFIT PLAN 2015 401k financial data
Transfers to/from the plan2015-08-31$-4,358
Total income from all sources2015-08-31$27,062
Expenses. Total of all expenses incurred2015-08-31$22,704
Benefits paid (including direct rollovers)2015-08-31$22,704
Total plan assets at end of year2015-08-31$3,050
Total plan assets at beginning of year2015-08-31$3,050
Total contributions received or receivable from participants2015-08-31$27,062
Net income (gross income less expenses)2015-08-31$4,358
Net plan assets at end of year (total assets less liabilities)2015-08-31$3,050
Net plan assets at beginning of year (total assets less liabilities)2015-08-31$3,050
2014 : UNIVERSITY LIGGETT SCHOOL WELFARE BENEFIT PLAN 2014 401k financial data
Transfers to/from the plan2014-08-31$-402
Total income from all sources2014-08-31$31,067
Expenses. Total of all expenses incurred2014-08-31$30,665
Benefits paid (including direct rollovers)2014-08-31$30,665
Total plan assets at end of year2014-08-31$2,650
Total plan assets at beginning of year2014-08-31$2,650
Total contributions received or receivable from participants2014-08-31$31,067
Net income (gross income less expenses)2014-08-31$402
Net plan assets at end of year (total assets less liabilities)2014-08-31$2,650
Net plan assets at beginning of year (total assets less liabilities)2014-08-31$2,650
2013 : UNIVERSITY LIGGETT SCHOOL WELFARE BENEFIT PLAN 2013 401k financial data
Transfers to/from the plan2013-08-31$-3,371
Total income from all sources2013-08-31$32,163
Expenses. Total of all expenses incurred2013-08-31$28,371
Benefits paid (including direct rollovers)2013-08-31$28,371
Total plan assets at end of year2013-08-31$2,650
Total plan assets at beginning of year2013-08-31$2,229
Total contributions received or receivable from participants2013-08-31$32,163
Net income (gross income less expenses)2013-08-31$3,792
Net plan assets at end of year (total assets less liabilities)2013-08-31$2,650
Net plan assets at beginning of year (total assets less liabilities)2013-08-31$2,229
2012 : UNIVERSITY LIGGETT SCHOOL WELFARE BENEFIT PLAN 2012 401k financial data
Transfers to/from the plan2012-08-31$-2,731
Total plan liabilities at beginning of year2012-08-31$0
Total income from all sources2012-08-31$41,980
Expenses. Total of all expenses incurred2012-08-31$39,751
Benefits paid (including direct rollovers)2012-08-31$39,751
Total plan assets at end of year2012-08-31$2,229
Total plan assets at beginning of year2012-08-31$2,731
Total contributions received or receivable from participants2012-08-31$41,980
Net income (gross income less expenses)2012-08-31$2,229
Net plan assets at end of year (total assets less liabilities)2012-08-31$2,229
Net plan assets at beginning of year (total assets less liabilities)2012-08-31$2,731
2011 : UNIVERSITY LIGGETT SCHOOL WELFARE BENEFIT PLAN 2011 401k financial data
Transfers to/from the plan2011-08-31$-4,182
Total plan liabilities at end of year2011-08-31$0
Total plan liabilities at beginning of year2011-08-31$0
Total income from all sources2011-08-31$43,648
Expenses. Total of all expenses incurred2011-08-31$40,917
Benefits paid (including direct rollovers)2011-08-31$40,917
Total plan assets at end of year2011-08-31$2,731
Total plan assets at beginning of year2011-08-31$4,182
Total contributions received or receivable from participants2011-08-31$43,648
Contributions received from other sources (not participants or employers)2011-08-31$0
Net income (gross income less expenses)2011-08-31$2,731
Net plan assets at end of year (total assets less liabilities)2011-08-31$2,731
Net plan assets at beginning of year (total assets less liabilities)2011-08-31$4,182
Total contributions received or receivable from employer(s)2011-08-31$0

Form 5500 Responses for UNIVERSITY LIGGETT SCHOOL WELFARE BENEFIT PLAN

2021: UNIVERSITY LIGGETT SCHOOL WELFARE BENEFIT PLAN 2021 form 5500 responses
2021-09-01Type of plan entitySingle employer plan
2021-09-01Plan funding arrangement – InsuranceYes
2021-09-01Plan funding arrangement – General assets of the sponsorYes
2021-09-01Plan benefit arrangement – InsuranceYes
2021-09-01Plan benefit arrangement – General assets of the sponsorYes
2020: UNIVERSITY LIGGETT SCHOOL WELFARE BENEFIT PLAN 2020 form 5500 responses
2020-09-01Type of plan entitySingle employer plan
2020-09-01Submission has been amendedNo
2020-09-01This submission is the final filingNo
2020-09-01This return/report is a short plan year return/report (less than 12 months)No
2020-09-01Plan is a collectively bargained planNo
2020-09-01Plan funding arrangement – InsuranceYes
2020-09-01Plan funding arrangement – General assets of the sponsorYes
2020-09-01Plan benefit arrangement – InsuranceYes
2020-09-01Plan benefit arrangement – General assets of the sponsorYes
2019: UNIVERSITY LIGGETT SCHOOL WELFARE BENEFIT PLAN 2019 form 5500 responses
2019-09-01Type of plan entitySingle employer plan
2019-09-01Submission has been amendedNo
2019-09-01This submission is the final filingNo
2019-09-01This return/report is a short plan year return/report (less than 12 months)No
2019-09-01Plan is a collectively bargained planNo
2019-09-01Plan funding arrangement – InsuranceYes
2019-09-01Plan funding arrangement – General assets of the sponsorYes
2019-09-01Plan benefit arrangement – InsuranceYes
2019-09-01Plan benefit arrangement – General assets of the sponsorYes
2018: UNIVERSITY LIGGETT SCHOOL WELFARE BENEFIT PLAN 2018 form 5500 responses
2018-09-01Type of plan entitySingle employer plan
2018-09-01Submission has been amendedNo
2018-09-01This submission is the final filingNo
2018-09-01This return/report is a short plan year return/report (less than 12 months)No
2018-09-01Plan is a collectively bargained planNo
2018-09-01Plan funding arrangement – InsuranceYes
2018-09-01Plan funding arrangement – General assets of the sponsorYes
2018-09-01Plan benefit arrangement – InsuranceYes
2018-09-01Plan benefit arrangement – General assets of the sponsorYes
2017: UNIVERSITY LIGGETT SCHOOL WELFARE BENEFIT PLAN 2017 form 5500 responses
2017-09-01Type of plan entitySingle employer plan
2017-09-01Submission has been amendedNo
2017-09-01This submission is the final filingNo
2017-09-01This return/report is a short plan year return/report (less than 12 months)No
2017-09-01Plan is a collectively bargained planNo
2017-09-01Plan funding arrangement – InsuranceYes
2017-09-01Plan funding arrangement – General assets of the sponsorYes
2017-09-01Plan benefit arrangement – InsuranceYes
2017-09-01Plan benefit arrangement – General assets of the sponsorYes
2016: UNIVERSITY LIGGETT SCHOOL WELFARE BENEFIT PLAN 2016 form 5500 responses
2016-09-01Type of plan entitySingle employer plan
2016-09-01Submission has been amendedNo
2016-09-01This submission is the final filingNo
2016-09-01This return/report is a short plan year return/report (less than 12 months)No
2016-09-01Plan is a collectively bargained planNo
2016-09-01Plan funding arrangement – InsuranceYes
2016-09-01Plan funding arrangement – General assets of the sponsorYes
2016-09-01Plan benefit arrangement – InsuranceYes
2016-09-01Plan benefit arrangement – General assets of the sponsorYes
2015: UNIVERSITY LIGGETT SCHOOL WELFARE BENEFIT PLAN 2015 form 5500 responses
2015-09-01Type of plan entitySingle employer plan
2015-09-01Submission has been amendedNo
2015-09-01This submission is the final filingNo
2015-09-01This return/report is a short plan year return/report (less than 12 months)No
2015-09-01Plan is a collectively bargained planNo
2015-09-01Plan funding arrangement – InsuranceYes
2015-09-01Plan funding arrangement – General assets of the sponsorYes
2015-09-01Plan benefit arrangement – InsuranceYes
2015-09-01Plan benefit arrangement – General assets of the sponsorYes
2014: UNIVERSITY LIGGETT SCHOOL WELFARE BENEFIT PLAN 2014 form 5500 responses
2014-09-01Type of plan entitySingle employer plan
2014-09-01Submission has been amendedNo
2014-09-01This submission is the final filingNo
2014-09-01This return/report is a short plan year return/report (less than 12 months)No
2014-09-01Plan is a collectively bargained planNo
2014-09-01Plan funding arrangement – InsuranceYes
2014-09-01Plan funding arrangement – General assets of the sponsorYes
2014-09-01Plan benefit arrangement – InsuranceYes
2014-09-01Plan benefit arrangement – General assets of the sponsorYes
2013: UNIVERSITY LIGGETT SCHOOL WELFARE BENEFIT PLAN 2013 form 5500 responses
2013-09-01Type of plan entitySingle employer plan
2013-09-01Submission has been amendedNo
2013-09-01This submission is the final filingNo
2013-09-01This return/report is a short plan year return/report (less than 12 months)No
2013-09-01Plan is a collectively bargained planNo
2013-09-01Plan funding arrangement – InsuranceYes
2013-09-01Plan funding arrangement – General assets of the sponsorYes
2013-09-01Plan benefit arrangement – InsuranceYes
2013-09-01Plan benefit arrangement – General assets of the sponsorYes
2012: UNIVERSITY LIGGETT SCHOOL WELFARE BENEFIT PLAN 2012 form 5500 responses
2012-09-01Type of plan entitySingle employer plan
2012-09-01Submission has been amendedNo
2012-09-01This submission is the final filingNo
2012-09-01This return/report is a short plan year return/report (less than 12 months)No
2012-09-01Plan is a collectively bargained planNo
2012-09-01Plan funding arrangement – InsuranceYes
2012-09-01Plan funding arrangement – General assets of the sponsorYes
2012-09-01Plan benefit arrangement – InsuranceYes
2012-09-01Plan benefit arrangement – General assets of the sponsorYes
2011: UNIVERSITY LIGGETT SCHOOL WELFARE BENEFIT PLAN 2011 form 5500 responses
2011-09-01Type of plan entitySingle employer plan
2011-09-01Submission has been amendedNo
2011-09-01This submission is the final filingNo
2011-09-01This return/report is a short plan year return/report (less than 12 months)No
2011-09-01Plan is a collectively bargained planNo
2011-09-01Plan funding arrangement – InsuranceYes
2011-09-01Plan funding arrangement – General assets of the sponsorYes
2011-09-01Plan benefit arrangement – InsuranceYes
2011-09-01Plan benefit arrangement – General assets of the sponsorYes
2010: UNIVERSITY LIGGETT SCHOOL WELFARE BENEFIT PLAN 2010 form 5500 responses
2010-09-01Type of plan entitySingle employer plan
2010-09-01Submission has been amendedNo
2010-09-01This submission is the final filingNo
2010-09-01This return/report is a short plan year return/report (less than 12 months)No
2010-09-01Plan is a collectively bargained planNo
2010-09-01Plan funding arrangement – InsuranceYes
2010-09-01Plan funding arrangement – General assets of the sponsorYes
2010-09-01Plan benefit arrangement – InsuranceYes
2010-09-01Plan benefit arrangement – General assets of the sponsorYes
2009: UNIVERSITY LIGGETT SCHOOL WELFARE BENEFIT PLAN 2009 form 5500 responses
2009-09-01Type of plan entitySingle employer plan
2009-09-01Submission has been amendedNo
2009-09-01This submission is the final filingNo
2009-09-01This return/report is a short plan year return/report (less than 12 months)No
2009-09-01Plan is a collectively bargained planNo
2009-09-01Plan funding arrangement – InsuranceYes
2009-09-01Plan funding arrangement – General assets of the sponsorYes
2009-09-01Plan benefit arrangement – InsuranceYes
2009-09-01Plan benefit arrangement – General assets of the sponsorYes

Insurance Providers Used on plan

METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number5938586
Policy instance 3
Insurance contract or identification number5938586
Number of Individuals Covered324
Insurance policy start date2022-09-01
Insurance policy end date2023-08-31
Total amount of commissions paid to insurance brokerUSD $10,541
Total amount of fees paid to insurance companyUSD $1,806
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $56,108
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $7,599
Amount paid for insurance broker fees1090
Additional information about fees paid to insurance brokerSUPPLEMENTAL COMPENSATION, NON-MONETARY COMPENSATION, MARKETING FEES
Insurance broker organization code?3
DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 )
Policy contract number3764
Policy instance 2
Insurance contract or identification number3764
Number of Individuals Covered288
Insurance policy start date2022-09-01
Insurance policy end date2023-08-31
Total amount of commissions paid to insurance brokerUSD $6,271
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6,271
Amount paid for insurance broker fees0
Insurance broker organization code?3
BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 )
Policy contract number158764
Policy instance 1
Insurance contract or identification number158764
Number of Individuals Covered261
Insurance policy start date2022-09-01
Insurance policy end date2023-08-31
Total amount of commissions paid to insurance brokerUSD $63,578
Total amount of fees paid to insurance companyUSD $1,240
Health Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $63,578
Amount paid for insurance broker fees0
Insurance broker organization code?3
Additional information about fees paid to insurance brokerFEES AND OTHER COMMISSIONS
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number5938586
Policy instance 3
Insurance contract or identification number5938586
Number of Individuals Covered194
Insurance policy start date2021-09-01
Insurance policy end date2022-08-31
Total amount of commissions paid to insurance brokerUSD $8,333
Total amount of fees paid to insurance companyUSD $1,586
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $51,436
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6,191
Amount paid for insurance broker fees1111
Additional information about fees paid to insurance brokerSUPPLEMENTAL COMPENSATION, NON-MONETARY COMPENSATION
Insurance broker organization code?3
DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 )
Policy contract number3764
Policy instance 2
Insurance contract or identification number3764
Number of Individuals Covered270
Insurance policy start date2021-09-01
Insurance policy end date2022-08-31
Total amount of commissions paid to insurance brokerUSD $6,988
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6,988
Amount paid for insurance broker fees0
Insurance broker organization code?3
BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 )
Policy contract number158764
Policy instance 1
Insurance contract or identification number158764
Number of Individuals Covered253
Insurance policy start date2021-09-01
Insurance policy end date2022-08-31
Total amount of commissions paid to insurance brokerUSD $73,340
Total amount of fees paid to insurance companyUSD $1,227
Health Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $73,340
Amount paid for insurance broker fees0
Insurance broker organization code?3
Additional information about fees paid to insurance brokerFEES AND OTHER COMMISSIONS
BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 )
Policy contract number158764
Policy instance 1
Insurance contract or identification number158764
Number of Individuals Covered239
Insurance policy start date2020-09-01
Insurance policy end date2021-08-31
Total amount of commissions paid to insurance brokerUSD $50,513
Total amount of fees paid to insurance companyUSD $1,049
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $50,513
Amount paid for insurance broker fees1049
Additional information about fees paid to insurance brokerCOMMISSION & INCENTIVE PAYMENTS
Insurance broker organization code?3
DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 )
Policy contract number3764
Policy instance 2
Insurance contract or identification number3764
Number of Individuals Covered261
Insurance policy start date2020-09-01
Insurance policy end date2021-08-31
Total amount of commissions paid to insurance brokerUSD $6,355
Total amount of fees paid to insurance companyUSD $119
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6,355
Amount paid for insurance broker fees119
Additional information about fees paid to insurance brokerRETENTION BONUS
Insurance broker organization code?3
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number5938586
Policy instance 3
Insurance contract or identification number5938586
Number of Individuals Covered282
Insurance policy start date2020-09-01
Insurance policy end date2021-08-31
Total amount of commissions paid to insurance brokerUSD $6,636
Total amount of fees paid to insurance companyUSD $389
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedADD
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $51,131
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6,636
Amount paid for insurance broker fees389
Additional information about fees paid to insurance brokerBASE COMMISSIONS
Insurance broker organization code?3
BLUE CARE NETWORK OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 95610 )
Policy contract number158764
Policy instance 4
Insurance contract or identification number158764
Number of Individuals Covered10
Insurance policy start date2020-09-01
Insurance policy end date2021-08-31
Total amount of commissions paid to insurance brokerUSD $1,328
Total amount of fees paid to insurance companyUSD $43
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,328
Amount paid for insurance broker fees43
Additional information about fees paid to insurance brokerCOMMISSION
Insurance broker organization code?3
BLUE CARE NETWORK OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 95610 )
Policy contract number158764
Policy instance 4
Insurance contract or identification number158764
Number of Individuals Covered9
Insurance policy start date2019-09-01
Insurance policy end date2020-08-31
Total amount of commissions paid to insurance brokerUSD $1,570
Total amount of fees paid to insurance companyUSD $40
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,570
Amount paid for insurance broker fees40
Additional information about fees paid to insurance brokerCOMMISSION
Insurance broker organization code?3
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number5938586
Policy instance 3
Insurance contract or identification number5938586
Number of Individuals Covered268
Insurance policy start date2019-09-01
Insurance policy end date2020-08-31
Total amount of commissions paid to insurance brokerUSD $6,551
Total amount of fees paid to insurance companyUSD $680
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedADD
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $51,023
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6,551
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerBASE COMMISSIONS
Insurance broker organization code?3
DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 )
Policy contract number3764
Policy instance 2
Insurance contract or identification number3764
Number of Individuals Covered253
Insurance policy start date2019-09-01
Insurance policy end date2020-08-31
Total amount of commissions paid to insurance brokerUSD $6,328
Total amount of fees paid to insurance companyUSD $231
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6,328
Amount paid for insurance broker fees231
Additional information about fees paid to insurance brokerRETENTION BONUS
Insurance broker organization code?3
BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 )
Policy contract number158764
Policy instance 1
Insurance contract or identification number158764
Number of Individuals Covered240
Insurance policy start date2019-09-01
Insurance policy end date2020-08-31
Total amount of commissions paid to insurance brokerUSD $53,260
Total amount of fees paid to insurance companyUSD $1,040
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $53,260
Amount paid for insurance broker fees1040
Additional information about fees paid to insurance brokerCOMMISSION & INCENTIVE PAYMENTS
Insurance broker organization code?3
BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 )
Policy contract number158764
Policy instance 4
Insurance contract or identification number158764
Number of Individuals Covered240
Insurance policy start date2018-09-01
Insurance policy end date2019-08-31
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 planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract numberTM05938586
Policy instance 3
Insurance contract or identification numberTM05938586
Number of Individuals Covered222
Insurance policy start date2018-09-01
Insurance policy end date2019-08-31
Total amount of commissions paid to insurance brokerUSD $5,917
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedADD
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $41,943
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,534
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerBASE COMMISSIONS
Insurance broker organization code?3
DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 )
Policy contract number3764
Policy instance 2
Insurance contract or identification number3764
Number of Individuals Covered254
Insurance policy start date2018-09-01
Insurance policy end date2019-08-31
Total amount of commissions paid to insurance brokerUSD $1,447
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,038
Insurance broker organization code?3
BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 )
Policy contract number158764
Policy instance 1
Insurance contract or identification number158764
Number of Individuals Covered240
Insurance policy start date2018-09-01
Insurance policy end date2019-08-31
Total amount of commissions paid to insurance brokerUSD $49,245
Total amount of fees paid to insurance companyUSD $4,050
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $45,496
Amount paid for insurance broker fees4050
Additional information about fees paid to insurance brokerCOMMISSION & INCENTIVE PAYMENTS
Insurance broker organization code?3
PRIORITY HEALTH (National Association of Insurance Commissioners NAIC id number: 95561 )
Policy contract numberS001
Policy instance 4
Insurance contract or identification numberS001
Number of Individuals Covered0
Insurance policy start date2017-09-01
Insurance policy end date2018-08-31
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 planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $465
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract numberTM05938586
Policy instance 3
Insurance contract or identification numberTM05938586
Number of Individuals Covered185
Insurance policy start date2017-09-01
Insurance policy end date2018-08-31
Total amount of commissions paid to insurance brokerUSD $4,365
Total amount of fees paid to insurance companyUSD $20
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedADD
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $32,020
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 )
Policy contract number3764
Policy instance 2
Insurance contract or identification number3764
Number of Individuals Covered251
Insurance policy start date2017-09-01
Insurance policy end date2018-08-31
Total amount of commissions paid to insurance brokerUSD $4,400
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
PRIORITY HEALTH (National Association of Insurance Commissioners NAIC id number: 12208 )
Policy contract numberS001
Policy instance 1
Insurance contract or identification numberS001
Number of Individuals Covered236
Insurance policy start date2017-09-01
Insurance policy end date2018-08-31
Total amount of commissions paid to insurance brokerUSD $41,519
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $1,037,982
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 )
Policy contract number158764
Policy instance 1
Insurance contract or identification number158764
Number of Individuals Covered88
Insurance policy start date2015-09-01
Insurance policy end date2016-08-31
Total amount of commissions paid to insurance brokerUSD $41,073
Total amount of fees paid to insurance companyUSD $846
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $41,073
Amount paid for insurance broker fees846
Additional information about fees paid to insurance brokerCOMMISSION & INCENTIVE PAYMENTS
Insurance broker organization code?3
Insurance broker nameKRISTOPHER F POWELL
DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 )
Policy contract number3764
Policy instance 2
Insurance contract or identification number3764
Number of Individuals Covered100
Insurance policy start date2015-09-01
Insurance policy end date2016-08-31
Total amount of commissions paid to insurance brokerUSD $5,761
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,761
Insurance broker organization code?3
Insurance broker nameBENEPRO, INC
BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 )
Policy contract number158764
Policy instance 1
Insurance contract or identification number158764
Number of Individuals Covered87
Insurance policy start date2014-09-01
Insurance policy end date2015-08-31
Total amount of commissions paid to insurance brokerUSD $44,516
Total amount of fees paid to insurance companyUSD $369
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $44,516
Amount paid for insurance broker fees369
Additional information about fees paid to insurance brokerCOMMISSION & INCENTIVE PAYMENTS
Insurance broker organization code?3
Insurance broker nameKRISTOPHER F POWELL
DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 )
Policy contract number3764
Policy instance 2
Insurance contract or identification number3764
Number of Individuals Covered98
Insurance policy start date2014-09-01
Insurance policy end date2015-08-31
Total amount of commissions paid to insurance brokerUSD $5,406
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,406
Insurance broker organization code?3
Insurance broker nameBENEPRO, INC
DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 )
Policy contract number3764
Policy instance 2
Insurance contract or identification number3764
Number of Individuals Covered97
Insurance policy start date2013-09-01
Insurance policy end date2014-08-31
Total amount of commissions paid to insurance brokerUSD $5,246
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,246
Insurance broker organization code?3
Insurance broker nameBENEPRO, INC
BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 )
Policy contract number158764
Policy instance 1
Insurance contract or identification number158764
Number of Individuals Covered87
Insurance policy start date2013-09-01
Insurance policy end date2014-08-31
Total amount of commissions paid to insurance brokerUSD $49,777
Total amount of fees paid to insurance companyUSD $715
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $49,777
Amount paid for insurance broker fees715
Additional information about fees paid to insurance brokerCOMMISSION & INCENTIVE PAYMENTS
Insurance broker organization code?3
Insurance broker nameKRISTOPHER F POWELL
DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 )
Policy contract number3764
Policy instance 2
Insurance contract or identification number3764
Number of Individuals Covered101
Insurance policy start date2012-09-01
Insurance policy end date2013-08-31
Total amount of commissions paid to insurance brokerUSD $5,332
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,332
Insurance broker organization code?3
Insurance broker nameBENEPRO, INC
BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 )
Policy contract number158764
Policy instance 1
Insurance contract or identification number158764
Number of Individuals Covered88
Insurance policy start date2012-09-01
Insurance policy end date2013-08-31
Total amount of commissions paid to insurance brokerUSD $66,338
Total amount of fees paid to insurance companyUSD $1,673
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $66,338
Amount paid for insurance broker fees1673
Additional information about fees paid to insurance brokerCOMMISSION & INCENTIVE PAYMENTS
Insurance broker organization code?3
Insurance broker nameKRISTOPHER F POWELL
BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 )
Policy contract number158764
Policy instance 1
Insurance contract or identification number158764
Number of Individuals Covered92
Insurance policy start date2011-09-01
Insurance policy end date2012-08-31
Total amount of commissions paid to insurance brokerUSD $63,538
Total amount of fees paid to insurance companyUSD $533
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 )
Policy contract number3764
Policy instance 2
Insurance contract or identification number3764
Number of Individuals Covered106
Insurance policy start date2011-09-01
Insurance policy end date2012-08-31
Total amount of commissions paid to insurance brokerUSD $5,477
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 )
Policy contract number3764
Policy instance 2
Insurance contract or identification number3764
Number of Individuals Covered106
Insurance policy start date2010-09-01
Insurance policy end date2011-08-31
Total amount of commissions paid to insurance brokerUSD $5,618
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 )
Policy contract number158764
Policy instance 1
Insurance contract or identification number158764
Number of Individuals Covered92
Insurance policy start date2010-09-01
Insurance policy end date2011-08-31
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $1,286,164
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No

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