RESTHAVEN has sponsored the creation of one or more 401k plans.
| Measure | Date | Value |
|---|
| 2021: RESTHAVEN GROUP BENEFIT PLAN 2021 401k membership |
|---|
| Total participants, beginning-of-year | 2021-10-01 | 236 |
| Total number of active participants reported on line 7a of the Form 5500 | 2021-10-01 | 235 |
| Number of retired or separated participants receiving benefits | 2021-10-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2021-10-01 | 0 |
| Total of all active and inactive participants | 2021-10-01 | 235 |
| Number of employers contributing to the scheme | 2021-10-01 | 0 |
| 2020: RESTHAVEN GROUP BENEFIT PLAN 2020 401k membership |
|---|
| Total participants, beginning-of-year | 2020-10-01 | 224 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-10-01 | 236 |
| Number of retired or separated participants receiving benefits | 2020-10-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2020-10-01 | 0 |
| Total of all active and inactive participants | 2020-10-01 | 236 |
| Number of employers contributing to the scheme | 2020-10-01 | 0 |
| 2019: RESTHAVEN GROUP BENEFIT PLAN 2019 401k membership |
|---|
| Total participants, beginning-of-year | 2019-10-01 | 218 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-10-01 | 224 |
| Number of retired or separated participants receiving benefits | 2019-10-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2019-10-01 | 0 |
| Total of all active and inactive participants | 2019-10-01 | 224 |
| Number of employers contributing to the scheme | 2019-10-01 | 0 |
| 2018: RESTHAVEN GROUP BENEFIT PLAN 2018 401k membership |
|---|
| Total participants, beginning-of-year | 2018-10-01 | 227 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-10-01 | 218 |
| Number of retired or separated participants receiving benefits | 2018-10-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2018-10-01 | 0 |
| Total of all active and inactive participants | 2018-10-01 | 218 |
| Number of employers contributing to the scheme | 2018-10-01 | 0 |
| 2017: RESTHAVEN GROUP BENEFIT PLAN 2017 401k membership |
|---|
| Total participants, beginning-of-year | 2017-10-01 | 223 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-10-01 | 227 |
| Total of all active and inactive participants | 2017-10-01 | 227 |
| Total participants | 2017-10-01 | 227 |
| 2016: RESTHAVEN GROUP BENEFIT PLAN 2016 401k membership |
|---|
| Total participants, beginning-of-year | 2016-10-01 | 223 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-10-01 | 223 |
| Total of all active and inactive participants | 2016-10-01 | 223 |
| Total participants | 2016-10-01 | 223 |
| 2015: RESTHAVEN GROUP BENEFIT PLAN 2015 401k membership |
|---|
| Total participants, beginning-of-year | 2015-10-01 | 222 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-10-01 | 223 |
| Number of retired or separated participants receiving benefits | 2015-10-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2015-10-01 | 0 |
| Total of all active and inactive participants | 2015-10-01 | 223 |
| Total participants | 2015-10-01 | 223 |
| 2014: RESTHAVEN GROUP BENEFIT PLAN 2014 401k membership |
|---|
| Total participants, beginning-of-year | 2014-10-01 | 226 |
| Total number of active participants reported on line 7a of the Form 5500 | 2014-10-01 | 222 |
| Total of all active and inactive participants | 2014-10-01 | 222 |
| Total participants | 2014-10-01 | 222 |
| 2013: RESTHAVEN GROUP BENEFIT PLAN 2013 401k membership |
|---|
| Total participants, beginning-of-year | 2013-10-01 | 224 |
| Total number of active participants reported on line 7a of the Form 5500 | 2013-10-01 | 226 |
| Total of all active and inactive participants | 2013-10-01 | 226 |
| Total participants | 2013-10-01 | 226 |
| 2012: RESTHAVEN GROUP BENEFIT PLAN 2012 401k membership |
|---|
| Total participants, beginning-of-year | 2012-10-01 | 224 |
| Total number of active participants reported on line 7a of the Form 5500 | 2012-10-01 | 224 |
| Total of all active and inactive participants | 2012-10-01 | 224 |
| Total participants | 2012-10-01 | 224 |
| 2011: RESTHAVEN GROUP BENEFIT PLAN 2011 401k membership |
|---|
| Total participants, beginning-of-year | 2011-10-01 | 214 |
| Total number of active participants reported on line 7a of the Form 5500 | 2011-10-01 | 214 |
| Total of all active and inactive participants | 2011-10-01 | 214 |
| Total participants | 2011-10-01 | 214 |
| 2010: RESTHAVEN GROUP BENEFIT PLAN 2010 401k membership |
|---|
| Total participants, beginning-of-year | 2010-10-01 | 209 |
| Total number of active participants reported on line 7a of the Form 5500 | 2010-10-01 | 214 |
| Number of retired or separated participants receiving benefits | 2010-10-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2010-10-01 | 0 |
| Total of all active and inactive participants | 2010-10-01 | 214 |
| Total participants | 2010-10-01 | 214 |
| 2009: RESTHAVEN GROUP BENEFIT PLAN 2009 401k membership |
|---|
| Total participants, beginning-of-year | 2009-10-01 | 209 |
| Total number of active participants reported on line 7a of the Form 5500 | 2009-10-01 | 209 |
| Number of retired or separated participants receiving benefits | 2009-10-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2009-10-01 | 0 |
| Total of all active and inactive participants | 2009-10-01 | 209 |
| Total participants | 2009-10-01 | 209 |
| 2007: RESTHAVEN GROUP BENEFIT PLAN 2007 401k membership |
|---|
| Total participants, beginning-of-year | 2007-10-01 | 193 |
| Total number of active participants reported on line 7a of the Form 5500 | 2007-10-01 | 201 |
| Number of retired or separated participants receiving benefits | 2007-10-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2007-10-01 | 0 |
| Total of all active and inactive participants | 2007-10-01 | 201 |
| Total participants | 2007-10-01 | 201 |
| 2003: RESTHAVEN GROUP BENEFIT PLAN 2003 401k membership |
|---|
| Total participants, beginning-of-year | 2003-10-01 | 179 |
| Total number of active participants reported on line 7a of the Form 5500 | 2003-10-01 | 184 |
| Number of retired or separated participants receiving benefits | 2003-10-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2003-10-01 | 0 |
| Total of all active and inactive participants | 2003-10-01 | 184 |
| Total participants | 2003-10-01 | 184 |
| 2002: RESTHAVEN GROUP BENEFIT PLAN 2002 401k membership |
|---|
| Total participants, beginning-of-year | 2002-10-01 | 179 |
| Total number of active participants reported on line 7a of the Form 5500 | 2002-10-01 | 179 |
| Number of retired or separated participants receiving benefits | 2002-10-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2002-10-01 | 0 |
| Total of all active and inactive participants | 2002-10-01 | 179 |
| Total participants | 2002-10-01 | 179 |
| 2021: RESTHAVEN GROUP BENEFIT PLAN 2021 form 5500 responses |
|---|
| 2021-10-01 | Type of plan entity | Single employer plan |
| 2021-10-01 | Plan funding arrangement – Insurance | Yes |
| 2021-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2021-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2021-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2020: RESTHAVEN GROUP BENEFIT PLAN 2020 form 5500 responses |
|---|
| 2020-10-01 | Type of plan entity | Single employer plan |
| 2020-10-01 | Plan funding arrangement – Insurance | Yes |
| 2020-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2020-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2020-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2019: RESTHAVEN GROUP BENEFIT PLAN 2019 form 5500 responses |
|---|
| 2019-10-01 | Type of plan entity | Single employer plan |
| 2019-10-01 | Plan funding arrangement – Insurance | Yes |
| 2019-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2019-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2019-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2018: RESTHAVEN GROUP BENEFIT PLAN 2018 form 5500 responses |
|---|
| 2018-10-01 | Type of plan entity | Single employer plan |
| 2018-10-01 | Plan funding arrangement – Insurance | Yes |
| 2018-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2018-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2018-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2017: RESTHAVEN GROUP BENEFIT PLAN 2017 form 5500 responses |
|---|
| 2017-10-01 | Type of plan entity | Single employer plan |
| 2017-10-01 | Submission has been amended | No |
| 2017-10-01 | This submission is the final filing | No |
| 2017-10-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2017-10-01 | Plan is a collectively bargained plan | No |
| 2017-10-01 | Plan funding arrangement – Insurance | Yes |
| 2017-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2017-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2017-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2016: RESTHAVEN GROUP BENEFIT PLAN 2016 form 5500 responses |
|---|
| 2016-10-01 | Type of plan entity | Single employer plan |
| 2016-10-01 | Submission has been amended | No |
| 2016-10-01 | This submission is the final filing | No |
| 2016-10-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2016-10-01 | Plan is a collectively bargained plan | No |
| 2016-10-01 | Plan funding arrangement – Insurance | Yes |
| 2016-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2016-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2016-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2015: RESTHAVEN GROUP BENEFIT PLAN 2015 form 5500 responses |
|---|
| 2015-10-01 | Type of plan entity | Single employer plan |
| 2015-10-01 | Submission has been amended | No |
| 2015-10-01 | This submission is the final filing | No |
| 2015-10-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2015-10-01 | Plan is a collectively bargained plan | No |
| 2015-10-01 | Plan funding arrangement – Insurance | Yes |
| 2015-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2015-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2015-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2014: RESTHAVEN GROUP BENEFIT PLAN 2014 form 5500 responses |
|---|
| 2014-10-01 | Type of plan entity | Single employer plan |
| 2014-10-01 | Submission has been amended | No |
| 2014-10-01 | This submission is the final filing | No |
| 2014-10-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2014-10-01 | Plan is a collectively bargained plan | No |
| 2014-10-01 | Plan funding arrangement – Insurance | Yes |
| 2014-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2014-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2014-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2013: RESTHAVEN GROUP BENEFIT PLAN 2013 form 5500 responses |
|---|
| 2013-10-01 | Type of plan entity | Single employer plan |
| 2013-10-01 | Submission has been amended | No |
| 2013-10-01 | This submission is the final filing | No |
| 2013-10-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2013-10-01 | Plan is a collectively bargained plan | No |
| 2013-10-01 | Plan funding arrangement – Insurance | Yes |
| 2013-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2013-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2013-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2012: RESTHAVEN GROUP BENEFIT PLAN 2012 form 5500 responses |
|---|
| 2012-10-01 | Type of plan entity | Single employer plan |
| 2012-10-01 | Submission has been amended | No |
| 2012-10-01 | This submission is the final filing | No |
| 2012-10-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2012-10-01 | Plan is a collectively bargained plan | No |
| 2012-10-01 | Plan funding arrangement – Insurance | Yes |
| 2012-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2012-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2012-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2011: RESTHAVEN GROUP BENEFIT PLAN 2011 form 5500 responses |
|---|
| 2011-10-01 | Type of plan entity | Single employer plan |
| 2011-10-01 | Submission has been amended | No |
| 2011-10-01 | This submission is the final filing | No |
| 2011-10-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2011-10-01 | Plan is a collectively bargained plan | No |
| 2011-10-01 | Plan funding arrangement – Insurance | Yes |
| 2011-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2011-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2011-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2010: RESTHAVEN GROUP BENEFIT PLAN 2010 form 5500 responses |
|---|
| 2010-10-01 | Type of plan entity | Single employer plan |
| 2010-10-01 | Submission has been amended | No |
| 2010-10-01 | This submission is the final filing | No |
| 2010-10-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2010-10-01 | Plan is a collectively bargained plan | No |
| 2010-10-01 | Plan funding arrangement – Insurance | Yes |
| 2010-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2010-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2010-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2009: RESTHAVEN GROUP BENEFIT PLAN 2009 form 5500 responses |
|---|
| 2009-10-01 | Type of plan entity | Single employer plan |
| 2009-10-01 | Submission has been amended | No |
| 2009-10-01 | This submission is the final filing | No |
| 2009-10-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2009-10-01 | Plan is a collectively bargained plan | No |
| 2009-10-01 | Plan funding arrangement – Insurance | Yes |
| 2009-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2009-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2009-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2007: RESTHAVEN GROUP BENEFIT PLAN 2007 form 5500 responses |
|---|
| 2007-10-01 | Type of plan entity | Single employer plan |
| 2007-10-01 | Submission has been amended | No |
| 2007-10-01 | This submission is the final filing | No |
| 2007-10-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2007-10-01 | Plan is a collectively bargained plan | No |
| 2007-10-01 | Plan funding arrangement – Insurance | Yes |
| 2007-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2007-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2007-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2003: RESTHAVEN GROUP BENEFIT PLAN 2003 form 5500 responses |
|---|
| 2003-10-01 | Type of plan entity | Single employer plan |
| 2003-10-01 | Submission has been amended | No |
| 2003-10-01 | This submission is the final filing | No |
| 2003-10-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2003-10-01 | Plan is a collectively bargained plan | No |
| 2003-10-01 | Plan funding arrangement – Insurance | Yes |
| 2003-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2003-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2003-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2002: RESTHAVEN GROUP BENEFIT PLAN 2002 form 5500 responses |
|---|
| 2002-10-01 | Type of plan entity | Single employer plan |
| 2002-10-01 | First time form 5500 has been submitted | Yes |
| 2002-10-01 | Submission has been amended | No |
| 2002-10-01 | This submission is the final filing | No |
| 2002-10-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2002-10-01 | Plan is a collectively bargained plan | No |
| 2002-10-01 | Plan funding arrangement – Insurance | Yes |
| 2002-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2002-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2002-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLTD0AXS5 |
| Policy instance | 2 |
| Insurance contract or identification number | GLTD0AXS5 | | Number of Individuals Covered | 235 | | Insurance policy start date | 2021-10-01 | | Insurance policy end date | 2022-09-30 | | Total amount of commissions paid to insurance broker | USD $15,807 | | Total amount of fees paid to insurance company | USD $5,243 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT,ACCIDENT | | Welfare Benefit Premiums Paid to Carrier | USD $142,758 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $15,807 | | Amount paid for insurance broker fees | 5243 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 30092701 |
| Policy instance | 1 |
| Insurance contract or identification number | 30092701 | | Number of Individuals Covered | 114 | | Insurance policy start date | 2021-10-01 | | Insurance policy end date | 2022-09-30 | | Total amount of commissions paid to insurance broker | USD $907 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $18,117 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $907 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLTD0AXS5 |
| Policy instance | 2 |
| Insurance contract or identification number | GLTD0AXS5 | | Number of Individuals Covered | 236 | | Insurance policy start date | 2020-10-01 | | Insurance policy end date | 2021-09-30 | | Total amount of commissions paid to insurance broker | USD $15,468 | | Total amount of fees paid to insurance company | USD $8,173 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $138,436 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $15,468 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 30092701 |
| Policy instance | 1 |
| Insurance contract or identification number | 30092701 | | Number of Individuals Covered | 131 | | Insurance policy start date | 2020-10-01 | | Insurance policy end date | 2021-09-30 | | Total amount of commissions paid to insurance broker | USD $3,676 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $17,354 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $2,877 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 30092701 |
| Policy instance | 1 |
| Insurance contract or identification number | 30092701 | | Number of Individuals Covered | 122 | | Insurance policy start date | 2019-10-01 | | Insurance policy end date | 2020-09-30 | | Total amount of commissions paid to insurance broker | USD $801 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $15,907 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $440 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLTD0AXS5 |
| Policy instance | 2 |
| Insurance contract or identification number | GLTD0AXS5 | | Number of Individuals Covered | 224 | | Insurance policy start date | 2019-10-01 | | Insurance policy end date | 2020-09-30 | | Total amount of commissions paid to insurance broker | USD $15,205 | | Total amount of fees paid to insurance company | USD $5,677 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $135,982 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,697 | | Amount paid for insurance broker fees | 5677 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLTD0AXS5 |
| Policy instance | 4 |
| Insurance contract or identification number | GLTD0AXS5 | | Number of Individuals Covered | 218 | | Insurance policy start date | 2018-10-01 | | Insurance policy end date | 2019-09-30 | | Total amount of commissions paid to insurance broker | USD $14,279 | | Total amount of fees paid to insurance company | USD $8,191 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $126,104 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $14,279 | | Amount paid for insurance broker fees | 8191 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 ) |
| Policy contract number | 7730 |
| Policy instance | 2 |
| Insurance contract or identification number | 7730 | | Number of Individuals Covered | 278 | | Insurance policy start date | 2018-10-01 | | Insurance policy end date | 2019-09-30 | | Total amount of commissions paid to insurance broker | USD $2,263 | | Total amount of fees paid to insurance company | USD $259 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,263 | | Amount paid for insurance broker fees | 259 | | Additional information about fees paid to insurance broker | NEW BUSINESS BONUS RETENTION BONUS | | Insurance broker organization code? | 3 |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 12-049684-0681 |
| Policy instance | 3 |
| Insurance contract or identification number | 12-049684-0681 | | Number of Individuals Covered | 131 | | Insurance policy start date | 2018-10-01 | | Insurance policy end date | 2019-09-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $16,354 | | 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: 95561 ) |
| Policy contract number | 772173 |
| Policy instance | 1 |
| Insurance contract or identification number | 772173 | | Number of Individuals Covered | 297 | | Insurance policy start date | 2018-10-01 | | Insurance policy end date | 2019-09-30 | | Total amount of commissions paid to insurance broker | USD $29,642 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,482,082 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $29,642 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUC0AXS5 |
| Policy instance | 5 |
| Insurance contract or identification number | GUC0AXS5 | | Number of Individuals Covered | 87 | | Insurance policy start date | 2017-10-01 | | Insurance policy end date | 2018-09-30 | | Total amount of commissions paid to insurance broker | USD $3,794 | | Total amount of fees paid to insurance company | USD $1,674 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | VOLUNTARY SHORT TERM DISABILITY | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $37,943 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG0AXS5 |
| Policy instance | 4 |
| Insurance contract or identification number | GLUG0AXS5 | | Number of Individuals Covered | 227 | | Insurance policy start date | 2017-10-01 | | Insurance policy end date | 2018-09-30 | | Total amount of commissions paid to insurance broker | USD $662 | | Total amount of fees paid to insurance company | USD $337 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | AD&D | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $6,624 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUG 0AXS5 |
| Policy instance | 3 |
| Insurance contract or identification number | GUG 0AXS5 | | Number of Individuals Covered | 8 | | Insurance policy start date | 2017-10-01 | | Insurance policy end date | 2018-09-30 | | Total amount of commissions paid to insurance broker | USD $822 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $8,219 | | 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: 95561 ) |
| Policy contract number | 772173 S003 |
| Policy instance | 1 |
| Insurance contract or identification number | 772173 S003 | | Number of Individuals Covered | 295 | | Insurance policy start date | 2017-10-01 | | Insurance policy end date | 2018-09-30 | | Total amount of commissions paid to insurance broker | USD $30,004 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $1,500,224 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUDH0AXS5 |
| Policy instance | 7 |
| Insurance contract or identification number | GUDH0AXS5 | | Number of Individuals Covered | 39 | | Insurance policy start date | 2017-10-01 | | Insurance policy end date | 2018-09-30 | | Total amount of commissions paid to insurance broker | USD $1,098 | | Total amount of fees paid to insurance company | USD $652 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENT VOLUNTARY | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $10,976 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 12049684 0681 |
| Policy instance | 8 |
| Insurance contract or identification number | 12049684 0681 | | Number of Individuals Covered | 128 | | Insurance policy start date | 2017-10-01 | | Insurance policy end date | 2018-09-30 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GVTL0AXS5 |
| Policy instance | 6 |
| Insurance contract or identification number | GVTL0AXS5 | | Number of Individuals Covered | 128 | | Insurance policy start date | 2017-10-01 | | Insurance policy end date | 2018-09-30 | | Total amount of commissions paid to insurance broker | USD $5,051 | | Total amount of fees paid to insurance company | USD $2,174 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | VOLUNTARY LIFE INSURANCE | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $36,124 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLTD0AXS5 |
| Policy instance | 2 |
| Insurance contract or identification number | GLTD0AXS5 | | Number of Individuals Covered | 227 | | Insurance policy start date | 2017-10-01 | | Insurance policy end date | 2018-10-01 | | Total amount of commissions paid to insurance broker | USD $3,857 | | Total amount of fees paid to insurance company | USD $2,181 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $37,137 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 12049684 0681 |
| Policy instance | 8 |
| Insurance contract or identification number | 12049684 0681 | | Number of Individuals Covered | 129 | | Insurance policy start date | 2015-10-01 | | Insurance policy end date | 2016-09-30 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUDH0AXS5 |
| Policy instance | 7 |
| Insurance contract or identification number | GUDH0AXS5 | | Number of Individuals Covered | 39 | | Insurance policy start date | 2015-10-01 | | Insurance policy end date | 2016-09-30 | | Total amount of commissions paid to insurance broker | USD $1,101 | | Total amount of fees paid to insurance company | USD $99 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENT VOLUNTARY | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $11,007 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,101 | | Amount paid for insurance broker fees | 99 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | LIGHTHOUSE INS GROUP INC. |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GVTL0AXS5 |
| Policy instance | 6 |
| Insurance contract or identification number | GVTL0AXS5 | | Number of Individuals Covered | 132 | | Insurance policy start date | 2015-10-01 | | Insurance policy end date | 2016-09-30 | | Total amount of commissions paid to insurance broker | USD $5,200 | | Total amount of fees paid to insurance company | USD $338 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | VOLUNTARY LIFE INSURANCE | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $37,778 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,200 | | Amount paid for insurance broker fees | 338 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | LIGHTHOUSE INS GROUP INC. |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUC 0AXS5 |
| Policy instance | 5 |
| Insurance contract or identification number | GUC 0AXS5 | | Number of Individuals Covered | 78 | | Insurance policy start date | 2015-10-01 | | Insurance policy end date | 2016-09-30 | | Total amount of commissions paid to insurance broker | USD $1,994 | | Total amount of fees paid to insurance company | USD $347 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | VOLUNTARY SHORT TERM DISABILITY | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $19,935 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,994 | | Amount paid for insurance broker fees | 347 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | LIGHTHOUSE INS GROUP INC. |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG0AXS5 |
| Policy instance | 4 |
| Insurance contract or identification number | GLUG0AXS5 | | Number of Individuals Covered | 223 | | Insurance policy start date | 2015-10-01 | | Insurance policy end date | 2016-09-30 | | Total amount of commissions paid to insurance broker | USD $536 | | Total amount of fees paid to insurance company | USD $45 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | AD&D | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $5,361 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $536 | | Amount paid for insurance broker fees | 45 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | LIGHTHOUSE INS GROUP INC. |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLTD0AXS5 |
| Policy instance | 2 |
| Insurance contract or identification number | GLTD0AXS5 | | Number of Individuals Covered | 223 | | Insurance policy start date | 2015-10-01 | | Insurance policy end date | 2016-09-30 | | Total amount of commissions paid to insurance broker | USD $3,776 | | Total amount of fees paid to insurance company | USD $306 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $35,522 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,776 | | Amount paid for insurance broker fees | 306 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | LIGHTHOUSE INS GROUP INC. |
|
| PRIORITY HEALTH (National Association of Insurance Commissioners NAIC id number: 95561 ) |
| Policy contract number | 772173 S003 |
| Policy instance | 1 |
| Insurance contract or identification number | 772173 S003 | | Number of Individuals Covered | 357 | | Insurance policy start date | 2015-10-01 | | Insurance policy end date | 2016-09-30 | | Total amount of commissions paid to insurance broker | USD $30,609 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $1,541,942 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $30,609 | | Insurance broker organization code? | 3 | | Insurance broker name | AMY MCCULLOCH |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUG 0AXS5 |
| Policy instance | 3 |
| Insurance contract or identification number | GUG 0AXS5 | | Number of Individuals Covered | 8 | | Insurance policy start date | 2015-10-01 | | Insurance policy end date | 2016-09-30 | | Total amount of commissions paid to insurance broker | USD $832 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $8,319 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $832 | | Insurance broker organization code? | 3 | | Insurance broker name | LIGHTHOUSE INS GROUP INC. |
|
| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | 10180114 |
| Policy instance | 2 |
| Insurance contract or identification number | 10180114 | | Number of Individuals Covered | 221 | | Insurance policy start date | 2014-10-01 | | Insurance policy end date | 2015-09-30 | | Total amount of commissions paid to insurance broker | USD $650 | | Total amount of fees paid to insurance company | USD $80 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | AD&D | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $4,916 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $650 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 80 | | Additional information about fees paid to insurance broker | BROKER BONUS | | Insurance broker name | LIGHTHOUSE-KEUNING INS GROUP |
|
| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | 10181217 |
| Policy instance | 7 |
| Insurance contract or identification number | 10181217 | | Number of Individuals Covered | 66 | | Insurance policy start date | 2014-10-01 | | Insurance policy end date | 2015-09-30 | | Total amount of commissions paid to insurance broker | USD $4,916 | | Total amount of fees paid to insurance company | USD $476 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $32,771 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 476 | | Additional information about fees paid to insurance broker | BROKER BONUS | | Insurance broker organization code? | 3 | | Commission paid to Insurance Broker | USD $4,916 | | Insurance broker name | LIGHTHOUSE INSURANCE GROUP INC |
|
| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | 10180115 |
| Policy instance | 3 |
| Insurance contract or identification number | 10180115 | | Number of Individuals Covered | 222 | | Insurance policy start date | 2014-10-01 | | Insurance policy end date | 2015-09-30 | | Total amount of commissions paid to insurance broker | USD $3,511 | | Total amount of fees paid to insurance company | USD $495 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $30,225 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,511 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 495 | | Additional information about fees paid to insurance broker | BROKER BONUS | | Insurance broker name | LIGHTHOUSE-KEUNING INS GROUP |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 12049684-0681 |
| Policy instance | 5 |
| Insurance contract or identification number | 12049684-0681 | | Number of Individuals Covered | 119 | | Insurance policy start date | 2015-10-01 | | Insurance policy end date | 2015-09-30 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | 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: 95561 ) |
| Policy contract number | 772173 S003 |
| Policy instance | 1 |
| Insurance contract or identification number | 772173 S003 | | Number of Individuals Covered | 358 | | Insurance policy start date | 2014-10-01 | | Insurance policy end date | 2015-09-30 | | Total amount of commissions paid to insurance broker | USD $30,305 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $1,534,102 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,544 | | Insurance broker organization code? | 3 | | Insurance broker name | CHARLES J. KETCHUM |
|
| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | 400001000 17277 |
| Policy instance | 4 |
| Insurance contract or identification number | 400001000 17277 | | Number of Individuals Covered | 276 | | Insurance policy start date | 2014-10-01 | | Insurance policy end date | 2015-09-30 | | Total amount of commissions paid to insurance broker | USD $5,174 | | Total amount of fees paid to insurance company | USD $530 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $34,493 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,174 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 530 | | Additional information about fees paid to insurance broker | BROKER BONUS | | Insurance broker name | LIGHTHOUSE-KEUNING INS GROUP |
|
| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | 404002796 |
| Policy instance | 6 |
| Insurance contract or identification number | 404002796 | | Number of Individuals Covered | 55 | | Insurance policy start date | 2014-10-01 | | Insurance policy end date | 2015-09-30 | | Total amount of commissions paid to insurance broker | USD $3,214 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $15,950 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,214 | | Insurance broker organization code? | 3 | | Insurance broker name | LIGHTHOUSE INS GROUP INC |
|
| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | 400001000 17277 |
| Policy instance | 4 |
| Insurance contract or identification number | 400001000 17277 | | Number of Individuals Covered | 276 | | Insurance policy start date | 2013-10-01 | | Insurance policy end date | 2014-09-30 | | Total amount of commissions paid to insurance broker | USD $4,832 | | Total amount of fees paid to insurance company | USD $1,668 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $32,213 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 1678 | | Additional information about fees paid to insurance broker | BROKER BONUS | | Insurance broker organization code? | 3 | | Commission paid to Insurance Broker | USD $4,832 | | Insurance broker name | LIGHTHOUSE INSURANCE GROUP INC |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 12049684-0681 |
| Policy instance | 5 |
| Insurance contract or identification number | 12049684-0681 | | Number of Individuals Covered | 122 | | Insurance policy start date | 2013-10-01 | | Insurance policy end date | 2014-09-30 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | 10180115 |
| Policy instance | 3 |
| Insurance contract or identification number | 10180115 | | Number of Individuals Covered | 226 | | Insurance policy start date | 2013-10-01 | | Insurance policy end date | 2014-09-30 | | Total amount of commissions paid to insurance broker | USD $3,524 | | Total amount of fees paid to insurance company | USD $1,542 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $30,486 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 1542 | | Additional information about fees paid to insurance broker | BROKER BONUS | | Insurance broker organization code? | 3 | | Commission paid to Insurance Broker | USD $3,524 | | Insurance broker name | LIGHTHOUSE INSURANCE GROUP, INC. |
|
| THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 ) |
| Policy contract number | 10180114 |
| Policy instance | 2 |
| Insurance contract or identification number | 10180114 | | Number of Individuals Covered | 226 | | Insurance policy start date | 2013-10-01 | | Insurance policy end date | 2014-09-30 | | Total amount of commissions paid to insurance broker | USD $647 | | Total amount of fees paid to insurance company | USD $247 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | AD&D | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $4,889 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 247 | | Additional information about fees paid to insurance broker | BROKER BONUS | | Insurance broker organization code? | 3 | | Commission paid to Insurance Broker | USD $647 | | Insurance broker name | LIGHTHOUSE INSURANCE GROUP INC |
|
| PRIORITY HEALTH (National Association of Insurance Commissioners NAIC id number: 95561 ) |
| Policy contract number | 772173 S003 |
| Policy instance | 1 |
| Insurance contract or identification number | 772173 S003 | | Number of Individuals Covered | 357 | | Insurance policy start date | 2013-10-01 | | Insurance policy end date | 2014-09-30 | | Total amount of commissions paid to insurance broker | USD $30,808 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $1,558,427 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $30,808 | | Insurance broker organization code? | 3 | | Insurance broker name | CHARLES J. KETCHUM |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | N1289/34864 |
| Policy instance | 1 |
| Insurance contract or identification number | N1289/34864 | | Number of Individuals Covered | 224 | | Insurance policy start date | 2012-10-01 | | Insurance policy end date | 2013-09-30 | | Total amount of commissions paid to insurance broker | USD $10,291 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | AD&D | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $90,725 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $10,291 | | Insurance broker organization code? | 3 | | Insurance broker name | LIGHTHOUSE INSURANCE GROUP, INC. |
|
| PRIORITY HEALTH (National Association of Insurance Commissioners NAIC id number: 95561 ) |
| Policy contract number | 772173 S003 |
| Policy instance | 2 |
| Insurance contract or identification number | 772173 S003 | | Number of Individuals Covered | 364 | | Insurance policy start date | 2012-10-01 | | Insurance policy end date | 2013-09-30 | | Total amount of commissions paid to insurance broker | USD $30,059 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $1,502,968 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $30,059 | | Insurance broker organization code? | 3 | | Insurance broker name | CHARLES J. KETCHUM |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | N1289/34864 |
| Policy instance | 2 |
| Insurance contract or identification number | N1289/34864 | | Number of Individuals Covered | 214 | | Insurance policy start date | 2011-10-01 | | Insurance policy end date | 2012-09-30 | | Total amount of commissions paid to insurance broker | USD $10,315 | | Total amount of fees paid to insurance company | USD $1,142 | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | 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 $90,644 | | 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: 95561 ) |
| Policy contract number | 772173 |
| Policy instance | 3 |
| Insurance contract or identification number | 772173 | | Number of Individuals Covered | 180 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2011-12-31 | | Total amount of commissions paid to insurance broker | USD $28,313 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,412,879 | | 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: 95561 ) |
| Policy contract number | 772173 S003 |
| Policy instance | 4 |
| Insurance contract or identification number | 772173 S003 | | Number of Individuals Covered | 372 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-09-30 | | Total amount of commissions paid to insurance broker | USD $22,670 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,134,835 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
| Policy contract number | 689981G |
| Policy instance | 1 |
| Insurance contract or identification number | 689981G | | Number of Individuals Covered | 170 | | Insurance policy start date | 2011-10-01 | | Insurance policy end date | 2012-09-30 | | Total amount of commissions paid to insurance broker | USD $-1 | | 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 $-12 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
| Policy contract number | 689981G |
| Policy instance | 1 |
| Insurance contract or identification number | 689981G | | Number of Individuals Covered | 257 | | Insurance policy start date | 2010-10-01 | | Insurance policy end date | 2011-09-30 | | Total amount of commissions paid to insurance broker | USD $7,841 | | Total amount of fees paid to insurance company | USD $794 | | 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 $70,619 | | 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: 95561 ) |
| Policy contract number | 772173 |
| Policy instance | 2 |
| Insurance contract or identification number | 772173 | | Insurance policy start date | 2010-01-01 | | Insurance policy end date | 2010-12-31 | | Total amount of commissions paid to insurance broker | USD $25,266 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,263,315 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | N1289 |
| Policy instance | 3 |
| Insurance contract or identification number | N1289 | | Number of Individuals Covered | 162 | | Insurance policy start date | 2010-10-01 | | Insurance policy end date | 2011-09-30 | | Total amount of commissions paid to insurance broker | USD $1,618 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $11,238 | | 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: 95561 ) |
| Policy contract number | 772173 |
| Policy instance | 2 |
| Insurance contract or identification number | 772173 | | Number of Individuals Covered | 168 | | Insurance policy start date | 2008-01-01 | | Insurance policy end date | 2008-12-31 | | Total amount of commissions paid to insurance broker | USD $23,380 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,275,633 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $23,380 | | Insurance broker organization code? | 3 | | Insurance broker name | KETCHUM, CHARLES J. |
|
| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
| Policy contract number | 689981G |
| Policy instance | 1 |
| Insurance contract or identification number | 689981G | | Number of Individuals Covered | 253 | | Insurance policy start date | 2008-10-01 | | Insurance policy end date | 2009-09-30 | | Total amount of commissions paid to insurance broker | USD $9,629 | | 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 $69,104 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $9,629 | | Insurance broker organization code? | 3 | | Insurance broker name | LIGHTHOUSE KEUNING INS. GRP. INC. |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | N112, N1357 |
| Policy instance | 3 |
| Insurance contract or identification number | N112, N1357 | | Number of Individuals Covered | 148 | | Insurance policy start date | 2008-10-01 | | Insurance policy end date | 2009-09-30 | | Total amount of commissions paid to insurance broker | USD $1,757 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $11,569 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $16 | | Insurance broker organization code? | 3 | | Insurance broker name | CHARLES J. KETCHUM |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 00372887 |
| Policy instance | 3 |
| Insurance contract or identification number | 00372887 | | Number of Individuals Covered | 149 | | Insurance policy start date | 2007-10-01 | | Insurance policy end date | 2008-09-30 | | Total amount of commissions paid to insurance broker | USD $3,316 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $10,465 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $65 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 309 | | Additional information about fees paid to insurance broker | BONUS | | Insurance broker name | CHARLES J. KETCHUM |
|
| PRIORITY HEALTH (National Association of Insurance Commissioners NAIC id number: 95561 ) |
| Policy contract number | 772173 |
| Policy instance | 2 |
| Insurance contract or identification number | 772173 | | Number of Individuals Covered | 159 | | Insurance policy start date | 2007-01-01 | | Insurance policy end date | 2007-12-31 | | Total amount of commissions paid to insurance broker | USD $26,149 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,200,828 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $26,149 | | Insurance broker organization code? | 3 | | Insurance broker name | KETCHUM, CHARLES J. |
|
| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
| Policy contract number | 689981G |
| Policy instance | 1 |
| Insurance contract or identification number | 689981G | | Number of Individuals Covered | 242 | | Insurance policy start date | 2007-10-01 | | Insurance policy end date | 2008-09-30 | | Total amount of commissions paid to insurance broker | USD $67,552 | | 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 $67,552 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,749 | | Insurance broker organization code? | 3 | | Insurance broker name | KETCHUM, CHARLES |
|
| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
| Policy contract number | GLT/0GL-689981 |
| Policy instance | 1 |
| Insurance contract or identification number | GLT/0GL-689981 | | Number of Individuals Covered | 240 | | Insurance policy start date | 2006-10-01 | | Insurance policy end date | 2007-09-30 | | Total amount of commissions paid to insurance broker | USD $8,287 | | 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 $62,886 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,287 | | Insurance broker organization code? | 3 | | Insurance broker name | KETCHUM, CHARLES J. |
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| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | N112, N1357 |
| Policy instance | 3 |
| Insurance contract or identification number | N112, N1357 | | Number of Individuals Covered | 151 | | Insurance policy start date | 2006-10-01 | | Insurance policy end date | 2007-09-30 | | Total amount of commissions paid to insurance broker | USD $1,577 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $10,241 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $31 | | Insurance broker organization code? | 3 | | Insurance broker name | CHARLES J. KETCHUM |
|
| PRIORITY HEALTH (National Association of Insurance Commissioners NAIC id number: 95561 ) |
| Policy contract number | 772173 |
| Policy instance | 2 |
| Insurance contract or identification number | 772173 | | Number of Individuals Covered | 154 | | Insurance policy start date | 2006-01-01 | | Insurance policy end date | 2006-12-31 | | Total amount of commissions paid to insurance broker | USD $5,761 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $288,053 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,761 | | Insurance broker organization code? | 3 | | Insurance broker name | KETCHUM, CHARLES J. |
|
| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
| Policy contract number | 0GL/GLT-689981 |
| Policy instance | 1 |
| Insurance contract or identification number | 0GL/GLT-689981 | | Number of Individuals Covered | 243 | | Insurance policy start date | 2005-10-01 | | Insurance policy end date | 2006-09-30 | | Total amount of commissions paid to insurance broker | USD $8,288 | | Total amount of fees paid to insurance company | USD $846 | | 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 $62,909 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,288 | | Amount paid for insurance broker fees | 846 | | Additional information about fees paid to insurance broker | BONUS | | Insurance broker organization code? | 3 | | Insurance broker name | KETCHUM, CHARLES J. |
|
| PRIORITY HEALTH (National Association of Insurance Commissioners NAIC id number: 95561 ) |
| Policy contract number | 772173 |
| Policy instance | 2 |
| Insurance contract or identification number | 772173 | | Number of Individuals Covered | 152 | | Insurance policy start date | 2005-01-01 | | Insurance policy end date | 2005-12-31 | | Total amount of commissions paid to insurance broker | USD $15,382 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $769,086 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $15,382 | | Insurance broker organization code? | 3 | | Insurance broker name | KETCHUM, CHARLES J. |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | N112, N1357 |
| Policy instance | 3 |
| Insurance contract or identification number | N112, N1357 | | Number of Individuals Covered | 145 | | Insurance policy start date | 2005-10-01 | | Insurance policy end date | 2006-09-30 | | Total amount of commissions paid to insurance broker | USD $258 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $10,145 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5 | | Insurance broker organization code? | 3 | | Insurance broker name | CHARLES J. KETCHUM |
|
| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
| Policy contract number | 0GL/GLT-689981 |
| Policy instance | 1 |
| Insurance contract or identification number | 0GL/GLT-689981 | | Number of Individuals Covered | 201 | | Insurance policy start date | 2004-10-01 | | Insurance policy end date | 2005-09-30 | | Total amount of commissions paid to insurance broker | USD $7,904 | | Total amount of fees paid to insurance company | USD $804 | | 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 $59,089 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,904 | | Amount paid for insurance broker fees | 804 | | Additional information about fees paid to insurance broker | BONUS | | Insurance broker organization code? | 3 | | Insurance broker name | KETCHUM, CHARLES J. |
|
| PRIORITY HEALTH (National Association of Insurance Commissioners NAIC id number: 95561 ) |
| Policy contract number | 772173 |
| Policy instance | 2 |
| Insurance contract or identification number | 772173 | | Number of Individuals Covered | 152 | | Insurance policy start date | 2004-01-01 | | Insurance policy end date | 2004-12-31 | | Total amount of commissions paid to insurance broker | USD $19,069 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $953,449 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $19,069 | | Insurance broker name | KETCHUM, CHARLES J. |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | N112 N1357 |
| Policy instance | 3 |
| Insurance contract or identification number | N112 N1357 | | Number of Individuals Covered | 134 | | Insurance policy start date | 2004-10-01 | | Insurance policy end date | 2005-09-30 | | Total amount of commissions paid to insurance broker | USD $1,766 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $3,850 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $35 | | Insurance broker organization code? | 3 | | Insurance broker name | CHARLES J. KETCHUM |
|
| PRIORITY HEALTH (National Association of Insurance Commissioners NAIC id number: 95561 ) |
| Policy contract number | 772173 |
| Policy instance | 2 |
| Insurance contract or identification number | 772173 | | Number of Individuals Covered | 146 | | Insurance policy start date | 2003-01-01 | | Insurance policy end date | 2003-12-31 | | Total amount of commissions paid to insurance broker | USD $15,373 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $768,654 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $15,373 | | Insurance broker organization code? | 3 | | Insurance broker name | KETCHUM, CHARLES J. |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 372887 |
| Policy instance | 3 |
| Insurance contract or identification number | 372887 | | Number of Individuals Covered | 127 | | Insurance policy start date | 2003-10-01 | | Insurance policy end date | 2004-09-30 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $9,324 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
| Policy contract number | OGL/GLT-689981 |
| Policy instance | 1 |
| Insurance contract or identification number | OGL/GLT-689981 | | Number of Individuals Covered | 244 | | Insurance policy start date | 2003-10-01 | | Insurance policy end date | 2004-09-30 | | Total amount of commissions paid to insurance broker | USD $8,104 | | 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 $59,808 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,104 | | Insurance broker organization code? | 3 | | Insurance broker name | KETCHUM, CHARLES J. |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 372887 |
| Policy instance | 3 |
| Insurance contract or identification number | 372887 | | Number of Individuals Covered | 127 | | Insurance policy start date | 2002-10-01 | | Insurance policy end date | 2003-09-30 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $8,467 | | 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: 95561 ) |
| Policy contract number | 772173 |
| Policy instance | 2 |
| Insurance contract or identification number | 772173 | | Number of Individuals Covered | 144 | | Insurance policy start date | 2002-01-01 | | Insurance policy end date | 2002-12-31 | | Total amount of commissions paid to insurance broker | USD $5,554 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $277,707 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,554 | | Insurance broker organization code? | 3 | | Insurance broker name | KETCHUM, CHARLES J. |
|
| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
| Policy contract number | GLT/0GL-689981 |
| Policy instance | 1 |
| Insurance contract or identification number | GLT/0GL-689981 | | Number of Individuals Covered | 179 | | Insurance policy start date | 2002-10-01 | | Insurance policy end date | 2003-09-30 | | Total amount of commissions paid to insurance broker | USD $7,009 | | 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 $44,688 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,009 | | Insurance broker organization code? | 3 | | Insurance broker name | KETCHUM, CHARLES J. |
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