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MICHIGAN TUBE SWAGERS & FAB INC EMPLOYEE BENEFIT PLAN 401k Plan overview

Plan NameMICHIGAN TUBE SWAGERS & FAB INC EMPLOYEE BENEFIT PLAN
Plan identification number 501

MICHIGAN TUBE SWAGERS & FAB INC EMPLOYEE BENEFIT PLAN Benefits

401k Plan TypeWelfare Benefit
Plan Features/Benefits
  • Health (other than dental or vision)
  • Life insurance
  • Dental

401k Sponsoring company profile

MICHIGAN TUBE SWAGERS & FABRICATORS INC FABRICATORS, INC. has sponsored the creation of one or more 401k plans.

Company Name:MICHIGAN TUBE SWAGERS & FABRICATORS INC FABRICATORS, INC.
Employer identification number (EIN):381543409
NAIC Classification:337000

Form 5500 Filing Information

Submission information for form 5500 for 401k plan MICHIGAN TUBE SWAGERS & FAB INC EMPLOYEE BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5012021-05-01JAMES PEACE2023-02-21
5012020-05-01JAMES PEACE2022-05-13
5012019-05-01JAMES PEACE2021-02-12
5012017-05-01JAMES PEACE2019-05-28
5012016-05-01
5012015-05-01
5012014-05-01
5012013-05-01
5012012-05-01JOE RESTIVO
5012011-05-01JOE RESTIVO
5012010-05-01JOE RESTIVO
5012009-05-01JOE RESTIVO

Plan Statistics for MICHIGAN TUBE SWAGERS & FAB INC EMPLOYEE BENEFIT PLAN

401k plan membership statisitcs for MICHIGAN TUBE SWAGERS & FAB INC EMPLOYEE BENEFIT PLAN

Measure Date Value
2021: MICHIGAN TUBE SWAGERS & FAB INC EMPLOYEE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year2021-05-01322
Total number of active participants reported on line 7a of the Form 55002021-05-01298
Number of retired or separated participants receiving benefits2021-05-010
Number of other retired or separated participants entitled to future benefits2021-05-010
Total of all active and inactive participants2021-05-01298
2020: MICHIGAN TUBE SWAGERS & FAB INC EMPLOYEE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year2020-05-01348
Total number of active participants reported on line 7a of the Form 55002020-05-01298
Number of retired or separated participants receiving benefits2020-05-010
Number of other retired or separated participants entitled to future benefits2020-05-010
Total of all active and inactive participants2020-05-01298
Total participants2020-05-01298
2019: MICHIGAN TUBE SWAGERS & FAB INC EMPLOYEE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year2019-05-01364
Total number of active participants reported on line 7a of the Form 55002019-05-01348
Total of all active and inactive participants2019-05-01348
Total participants2019-05-01348
2017: MICHIGAN TUBE SWAGERS & FAB INC EMPLOYEE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year2017-05-01381
Total number of active participants reported on line 7a of the Form 55002017-05-01371
Total of all active and inactive participants2017-05-01371
2016: MICHIGAN TUBE SWAGERS & FAB INC EMPLOYEE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year2016-05-01357
Total number of active participants reported on line 7a of the Form 55002016-05-01381
Total of all active and inactive participants2016-05-01381
2015: MICHIGAN TUBE SWAGERS & FAB INC EMPLOYEE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year2015-05-01347
Total number of active participants reported on line 7a of the Form 55002015-05-01357
Total of all active and inactive participants2015-05-01357
2014: MICHIGAN TUBE SWAGERS & FAB INC EMPLOYEE BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year2014-05-01344
Total number of active participants reported on line 7a of the Form 55002014-05-01347
Total of all active and inactive participants2014-05-01347
2013: MICHIGAN TUBE SWAGERS & FAB INC EMPLOYEE BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year2013-05-01348
Total number of active participants reported on line 7a of the Form 55002013-05-01344
Total of all active and inactive participants2013-05-01344
2012: MICHIGAN TUBE SWAGERS & FAB INC EMPLOYEE BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year2012-05-01280
Total number of active participants reported on line 7a of the Form 55002012-05-01348
Number of retired or separated participants receiving benefits2012-05-010
Total of all active and inactive participants2012-05-01348
2011: MICHIGAN TUBE SWAGERS & FAB INC EMPLOYEE BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year2011-05-01265
Total number of active participants reported on line 7a of the Form 55002011-05-01280
Number of retired or separated participants receiving benefits2011-05-010
Total of all active and inactive participants2011-05-01280
2010: MICHIGAN TUBE SWAGERS & FAB INC EMPLOYEE BENEFIT PLAN 2010 401k membership
Total participants, beginning-of-year2010-05-01356
Total number of active participants reported on line 7a of the Form 55002010-05-01262
Number of retired or separated participants receiving benefits2010-05-013
Total of all active and inactive participants2010-05-01265
2009: MICHIGAN TUBE SWAGERS & FAB INC EMPLOYEE BENEFIT PLAN 2009 401k membership
Total participants, beginning-of-year2009-05-01368
Total number of active participants reported on line 7a of the Form 55002009-05-01264
Number of retired or separated participants receiving benefits2009-05-013
Total of all active and inactive participants2009-05-01267

Form 5500 Responses for MICHIGAN TUBE SWAGERS & FAB INC EMPLOYEE BENEFIT PLAN

2021: MICHIGAN TUBE SWAGERS & FAB INC EMPLOYEE BENEFIT PLAN 2021 form 5500 responses
2021-05-01Type of plan entitySingle employer plan
2021-05-01Plan funding arrangement – InsuranceYes
2021-05-01Plan funding arrangement – General assets of the sponsorYes
2021-05-01Plan benefit arrangement – InsuranceYes
2021-05-01Plan benefit arrangement – General assets of the sponsorYes
2020: MICHIGAN TUBE SWAGERS & FAB INC EMPLOYEE BENEFIT PLAN 2020 form 5500 responses
2020-05-01Type of plan entitySingle employer plan
2020-05-01Plan funding arrangement – InsuranceYes
2020-05-01Plan funding arrangement – General assets of the sponsorYes
2020-05-01Plan benefit arrangement – InsuranceYes
2020-05-01Plan benefit arrangement – General assets of the sponsorYes
2019: MICHIGAN TUBE SWAGERS & FAB INC EMPLOYEE BENEFIT PLAN 2019 form 5500 responses
2019-05-01Type of plan entitySingle employer plan
2019-05-01Plan funding arrangement – InsuranceYes
2019-05-01Plan funding arrangement – General assets of the sponsorYes
2019-05-01Plan benefit arrangement – InsuranceYes
2019-05-01Plan benefit arrangement – General assets of the sponsorYes
2017: MICHIGAN TUBE SWAGERS & FAB INC EMPLOYEE BENEFIT PLAN 2017 form 5500 responses
2017-05-01Type of plan entitySingle employer plan
2017-05-01Plan funding arrangement – InsuranceYes
2017-05-01Plan funding arrangement – General assets of the sponsorYes
2017-05-01Plan benefit arrangement – InsuranceYes
2017-05-01Plan benefit arrangement – General assets of the sponsorYes
2016: MICHIGAN TUBE SWAGERS & FAB INC EMPLOYEE BENEFIT PLAN 2016 form 5500 responses
2016-05-01Type of plan entitySingle employer plan
2016-05-01Plan funding arrangement – InsuranceYes
2016-05-01Plan funding arrangement – General assets of the sponsorYes
2016-05-01Plan benefit arrangement – InsuranceYes
2016-05-01Plan benefit arrangement – General assets of the sponsorYes
2015: MICHIGAN TUBE SWAGERS & FAB INC EMPLOYEE BENEFIT PLAN 2015 form 5500 responses
2015-05-01Type of plan entitySingle employer plan
2015-05-01Plan funding arrangement – InsuranceYes
2015-05-01Plan funding arrangement – General assets of the sponsorYes
2015-05-01Plan benefit arrangement – InsuranceYes
2015-05-01Plan benefit arrangement – General assets of the sponsorYes
2014: MICHIGAN TUBE SWAGERS & FAB INC EMPLOYEE BENEFIT PLAN 2014 form 5500 responses
2014-05-01Type of plan entitySingle employer plan
2014-05-01Plan funding arrangement – InsuranceYes
2014-05-01Plan funding arrangement – General assets of the sponsorYes
2014-05-01Plan benefit arrangement – InsuranceYes
2014-05-01Plan benefit arrangement – General assets of the sponsorYes
2013: MICHIGAN TUBE SWAGERS & FAB INC EMPLOYEE BENEFIT PLAN 2013 form 5500 responses
2013-05-01Type of plan entitySingle employer plan
2013-05-01Plan funding arrangement – InsuranceYes
2013-05-01Plan funding arrangement – General assets of the sponsorYes
2013-05-01Plan benefit arrangement – InsuranceYes
2013-05-01Plan benefit arrangement – General assets of the sponsorYes
2012: MICHIGAN TUBE SWAGERS & FAB INC EMPLOYEE BENEFIT PLAN 2012 form 5500 responses
2012-05-01Type of plan entitySingle employer plan
2012-05-01Plan funding arrangement – InsuranceYes
2012-05-01Plan funding arrangement – General assets of the sponsorYes
2012-05-01Plan benefit arrangement – InsuranceYes
2012-05-01Plan benefit arrangement – General assets of the sponsorYes
2011: MICHIGAN TUBE SWAGERS & FAB INC EMPLOYEE BENEFIT PLAN 2011 form 5500 responses
2011-05-01Type of plan entitySingle employer plan
2011-05-01Plan funding arrangement – InsuranceYes
2011-05-01Plan funding arrangement – General assets of the sponsorYes
2011-05-01Plan benefit arrangement – InsuranceYes
2011-05-01Plan benefit arrangement – General assets of the sponsorYes
2010: MICHIGAN TUBE SWAGERS & FAB INC EMPLOYEE BENEFIT PLAN 2010 form 5500 responses
2010-05-01Type of plan entitySingle employer plan
2010-05-01Plan funding arrangement – InsuranceYes
2010-05-01Plan funding arrangement – General assets of the sponsorYes
2010-05-01Plan benefit arrangement – InsuranceYes
2010-05-01Plan benefit arrangement – General assets of the sponsorYes
2009: MICHIGAN TUBE SWAGERS & FAB INC EMPLOYEE BENEFIT PLAN 2009 form 5500 responses
2009-05-01Type of plan entitySingle employer plan
2009-05-01This submission is the final filingNo
2009-05-01Plan funding arrangement – InsuranceYes
2009-05-01Plan funding arrangement – General assets of the sponsorYes
2009-05-01Plan benefit arrangement – InsuranceYes
2009-05-01Plan benefit arrangement – General assets of the sponsorYes

Insurance Providers Used on plan

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number574611
Policy instance 3
Insurance contract or identification number574611
Number of Individuals Covered10
Insurance policy start date2022-05-01
Insurance policy end date2023-05-01
Total amount of commissions paid to insurance brokerUSD $2,357
Total amount of fees paid to insurance companyUSD $0
Long Term Disability Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,357
Insurance broker organization code?1
MEDICAL MUTUAL OF OHIO (National Association of Insurance Commissioners NAIC id number: 52429 )
Policy contract number
Policy instance 2
Number of Individuals Covered193
Insurance policy start date2022-05-01
Insurance policy end date2023-05-01
Total amount of commissions paid to insurance brokerUSD $23,110
Total amount of fees paid to insurance companyUSD $5,470
Health Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $23,110
Amount paid for insurance broker fees5470
Insurance broker organization code?2
DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 )
Policy contract number9794-0001,0002
Policy instance 1
Insurance contract or identification number9794-0001,0002
Number of Individuals Covered506
Insurance policy start date2022-05-01
Insurance policy end date2023-04-30
Total amount of commissions paid to insurance brokerUSD $3,203
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,203
Amount paid for insurance broker fees0
Insurance broker organization code?1
MEDICAL MUTUAL OF OHIO (National Association of Insurance Commissioners NAIC id number: 29076 )
Policy contract number
Policy instance 2
Number of Individuals Covered322
Insurance policy start date2021-05-01
Insurance policy end date2022-05-01
Total amount of commissions paid to insurance brokerUSD $34,125
Total amount of fees paid to insurance companyUSD $7,544
Health Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $34,125
Amount paid for insurance broker fees7544
Insurance broker organization code?2
DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 )
Policy contract number9794-0001,0002
Policy instance 1
Insurance contract or identification number9794-0001,0002
Insurance policy start date2021-05-01
Insurance policy end date2022-04-30
Total amount of commissions paid to insurance brokerUSD $14,028
Total amount of fees paid to insurance companyUSD $5,245
Dental Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $14,028
Amount paid for insurance broker fees5245
Insurance broker organization code?1
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number574611
Policy instance 3
Insurance contract or identification number574611
Number of Individuals Covered8
Insurance policy start date2021-05-01
Insurance policy end date2022-05-01
Total amount of commissions paid to insurance brokerUSD $2,519
Total amount of fees paid to insurance companyUSD $0
Long Term Disability Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,519
Insurance broker organization code?1
MEDICAL MUTUAL OF OHIO (National Association of Insurance Commissioners NAIC id number: 29076 )
Policy contract number
Policy instance 2
Number of Individuals Covered298
Insurance policy start date2020-05-01
Insurance policy end date2021-05-01
Total amount of commissions paid to insurance brokerUSD $35,810
Total amount of fees paid to insurance companyUSD $7,608
Health Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $35,810
Amount paid for insurance broker fees7608
Insurance broker organization code?2
PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )
Policy contract number0000130239
Policy instance 3
Insurance contract or identification number0000130239
Insurance policy start date2020-05-01
Insurance policy end date2021-05-01
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Temporary Disability Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Insurance broker organization code?3
PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )
Policy contract number138868
Policy instance 4
Insurance contract or identification number138868
Number of Individuals Covered1
Insurance policy start date2020-05-01
Insurance policy end date2021-05-01
Total amount of commissions paid to insurance brokerUSD $31
Total amount of fees paid to insurance companyUSD $0
Long Term Disability Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Insurance broker organization code?2
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number574611
Policy instance 5
Insurance contract or identification number574611
Number of Individuals Covered8
Insurance policy start date2020-05-01
Insurance policy end date2021-05-01
Total amount of commissions paid to insurance brokerUSD $2,368
Total amount of fees paid to insurance companyUSD $0
Long Term Disability Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,368
Insurance broker organization code?1
DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 )
Policy contract number9794-0001,0002
Policy instance 1
Insurance contract or identification number9794-0001,0002
Insurance policy start date2020-05-01
Insurance policy end date2021-04-30
Total amount of commissions paid to insurance brokerUSD $13,127
Total amount of fees paid to insurance companyUSD $4,788
Dental Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $13,127
Amount paid for insurance broker fees4788
Insurance broker organization code?1
DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 )
Policy contract number9794-0001,0002
Policy instance 1
Insurance contract or identification number9794-0001,0002
Number of Individuals Covered824
Insurance policy start date2019-05-01
Insurance policy end date2020-04-30
Total amount of commissions paid to insurance brokerUSD $6,775
Total amount of fees paid to insurance companyUSD $830
Dental Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6,775
Amount paid for insurance broker fees830
Insurance broker organization code?1
PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )
Policy contract number0000130239
Policy instance 3
Insurance contract or identification number0000130239
Number of Individuals Covered6
Insurance policy start date2019-05-01
Insurance policy end date2020-05-01
Total amount of commissions paid to insurance brokerUSD $308
Total amount of fees paid to insurance companyUSD $0
Temporary Disability Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $162
Insurance broker organization code?3
PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )
Policy contract number138868
Policy instance 4
Insurance contract or identification number138868
Number of Individuals Covered1
Insurance policy start date2019-05-01
Insurance policy end date2020-05-01
Total amount of commissions paid to insurance brokerUSD $31
Total amount of fees paid to insurance companyUSD $0
Long Term Disability Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $31
Insurance broker organization code?2
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number574611
Policy instance 5
Insurance contract or identification number574611
Number of Individuals Covered9
Insurance policy start date2019-05-01
Insurance policy end date2020-05-01
Total amount of commissions paid to insurance brokerUSD $1,633
Total amount of fees paid to insurance companyUSD $0
Long Term Disability Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,633
Insurance broker organization code?1
MEDICAL MUTUAL OF OHIO (National Association of Insurance Commissioners NAIC id number: 29076 )
Policy contract number
Policy instance 2
Number of Individuals Covered348
Insurance policy start date2019-05-01
Insurance policy end date2020-05-01
Total amount of commissions paid to insurance brokerUSD $41,800
Total amount of fees paid to insurance companyUSD $8,047
Health Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $41,800
Amount paid for insurance broker fees8047
Insurance broker organization code?2
PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )
Policy contract number138868
Policy instance 4
Insurance contract or identification number138868
Number of Individuals Covered1
Insurance policy start date2017-05-01
Insurance policy end date2018-05-01
Total amount of commissions paid to insurance brokerUSD $33
Total amount of fees paid to insurance companyUSD $0
Long Term Disability Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )
Policy contract number0000130239
Policy instance 3
Insurance contract or identification number0000130239
Number of Individuals Covered9
Insurance policy start date2017-05-01
Insurance policy end date2018-05-01
Total amount of commissions paid to insurance brokerUSD $780
Total amount of fees paid to insurance companyUSD $0
Temporary Disability Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
MEDICAL MUTUAL OF OHIO (National Association of Insurance Commissioners NAIC id number: 29076 )
Policy contract number
Policy instance 2
Number of Individuals Covered371
Insurance policy start date2017-05-01
Insurance policy end date2018-05-01
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 )
Policy contract number9794-0001,0002
Policy instance 1
Insurance contract or identification number9794-0001,0002
Number of Individuals Covered880
Insurance policy start date2017-05-01
Insurance policy end date2018-04-30
Total amount of commissions paid to insurance brokerUSD $6,872
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )
Policy contract number138868
Policy instance 5
Insurance contract or identification number138868
Number of Individuals Covered1
Insurance policy start date2015-05-01
Insurance policy end date2016-05-01
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $33
Long Term Disability Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Amount paid for insurance broker fees33
Insurance broker nameUSI INSURANCE SERVICES LLC
PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )
Policy contract number0000130239
Policy instance 4
Insurance contract or identification number0000130239
Number of Individuals Covered7
Insurance policy start date2015-05-01
Insurance policy end date2016-05-01
Total amount of commissions paid to insurance brokerUSD $233
Total amount of fees paid to insurance companyUSD $0
Temporary Disability Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $233
Insurance broker organization code?3
Insurance broker nameUSI INSURANCE SERVICES LLC
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number574611
Policy instance 3
Insurance contract or identification number574611
Number of Individuals Covered10
Insurance policy start date2015-05-01
Insurance policy end date2016-05-01
Total amount of commissions paid to insurance brokerUSD $1,813
Total amount of fees paid to insurance companyUSD $91
Long Term Disability Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,813
Amount paid for insurance broker fees91
Insurance broker organization code?3
Insurance broker nameUSI INSURANCE SERVICES LLC
MEDICAL MUTUAL OF OHIO (National Association of Insurance Commissioners NAIC id number: 29076 )
Policy contract number
Policy instance 2
Number of Individuals Covered357
Insurance policy start date2015-05-01
Insurance policy end date2016-05-01
Total amount of commissions paid to insurance brokerUSD $42,880
Total amount of fees paid to insurance companyUSD $46
Health Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $42,880
Amount paid for insurance broker fees46
Insurance broker organization code?3
Insurance broker nameBROOKS INSURANCE AGENCY, INC.
DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 )
Policy contract number9794-0001,0002
Policy instance 1
Insurance contract or identification number9794-0001,0002
Number of Individuals Covered858
Insurance policy start date2015-05-01
Insurance policy end date2016-04-30
Total amount of commissions paid to insurance brokerUSD $5,268
Total amount of fees paid to insurance companyUSD $16,829
Dental Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,268
Amount paid for insurance broker fees16829
Insurance broker organization code?3
Insurance broker nameBROOKS INSURANCE AGENCY, INC.
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberG000AJNW
Policy instance 3
Insurance contract or identification numberG000AJNW
Number of Individuals Covered347
Insurance policy start date2014-05-01
Insurance policy end date2015-04-30
Total amount of commissions paid to insurance brokerUSD $964
Total amount of fees paid to insurance companyUSD $16,140
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Other welfare benefits providedAD&D AND LIFE
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Amount paid for insurance broker fees16140
Additional information about fees paid to insurance brokerADMINISTRATIVE
Commission paid to Insurance BrokerUSD $964
Insurance broker organization code?3
Insurance broker nameBROOKS INSURANCE AGENCY, INC.
MEDICAL MUTUAL OF OHIO (National Association of Insurance Commissioners NAIC id number: 29076 )
Policy contract number
Policy instance 2
Number of Individuals Covered329
Insurance policy start date2014-05-01
Insurance policy end date2015-05-01
Total amount of commissions paid to insurance brokerUSD $39,420
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Health Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $39,420
Insurance broker organization code?3
Insurance broker nameBROOKS INSURANCE AGENCY, INC.
DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 )
Policy contract number9794-0001,0002
Policy instance 1
Insurance contract or identification number9794-0001,0002
Number of Individuals Covered782
Insurance policy start date2014-05-01
Insurance policy end date2015-04-30
Total amount of commissions paid to insurance brokerUSD $5,501
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Dental Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,501
Insurance broker organization code?4
Insurance broker nameBROOKS INSURANCE AGENCY, INC.
MEDICAL MUTUAL OF OHIO (National Association of Insurance Commissioners NAIC id number: 29076 )
Policy contract number
Policy instance 2
Number of Individuals Covered340
Insurance policy start date2013-05-01
Insurance policy end date2014-04-30
Total amount of commissions paid to insurance brokerUSD $40,790
Total amount of fees paid to insurance companyUSD $111
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Health Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $40,790
Amount paid for insurance broker fees111
Insurance broker organization code?3
Insurance broker nameBROOKS INSURANCE AGENCY, INC.
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberG000AJNW
Policy instance 3
Insurance contract or identification numberG000AJNW
Number of Individuals Covered344
Insurance policy start date2013-05-01
Insurance policy end date2014-04-30
Total amount of commissions paid to insurance brokerUSD $4,455
Total amount of fees paid to insurance companyUSD $1,462
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Other welfare benefits providedAD&D AND LIFE
Welfare Benefit Premiums Paid to CarrierUSD $30,465
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,793
Amount paid for insurance broker fees1462
Insurance broker organization code?3
Insurance broker nameROY LAMPHIER
DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 )
Policy contract number9794-0001,0002
Policy instance 1
Insurance contract or identification number9794-0001,0002
Number of Individuals Covered801
Insurance policy start date2013-04-01
Insurance policy end date2014-03-31
Total amount of commissions paid to insurance brokerUSD $4,984
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Dental Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,984
Insurance broker organization code?4
Insurance broker nameBROOKS INSURANCE AGENCY, INC.
DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 )
Policy contract number9794-0001,0002
Policy instance 1
Insurance contract or identification number9794-0001,0002
Number of Individuals Covered838
Insurance policy start date2012-05-01
Insurance policy end date2013-04-30
Total amount of commissions paid to insurance brokerUSD $5,384
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Dental Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,384
Insurance broker organization code?4
Insurance broker nameBROOKS INSURANCE AGENCY, INC.
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number574611
Policy instance 4
Insurance contract or identification number574611
Number of Individuals Covered10
Insurance policy start date2012-05-01
Insurance policy end date2013-04-30
Total amount of commissions paid to insurance brokerUSD $1,805
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Life Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,805
Insurance broker organization code?3
Insurance broker nameBROOKS INSURANCE AGENCY, INC.
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberG000AJNW
Policy instance 3
Insurance contract or identification numberG000AJNW
Number of Individuals Covered370
Insurance policy start date2012-05-01
Insurance policy end date2013-04-30
Total amount of commissions paid to insurance brokerUSD $9,299
Total amount of fees paid to insurance companyUSD $-113
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Other welfare benefits providedAD&D AND LIFE
Welfare Benefit Premiums Paid to CarrierUSD $29,614
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6,323
Amount paid for insurance broker fees-113
Insurance broker organization code?3
Insurance broker nameBROOKS INSURANCE AGENCY, INC.
MEDICAL MUTUAL OF OHIO (National Association of Insurance Commissioners NAIC id number: 29076 )
Policy contract number
Policy instance 2
Number of Individuals Covered340
Insurance policy start date2012-05-01
Insurance policy end date2013-04-30
Total amount of commissions paid to insurance brokerUSD $40,740
Total amount of fees paid to insurance companyUSD $49,883
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Health Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $40,740
Amount paid for insurance broker fees4667
Insurance broker organization code?3
Insurance broker nameBUSINESS DISTRIBUTION SOLUTIONS
DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 )
Policy contract number9794-0001,0002
Policy instance 1
Insurance contract or identification number9794-0001,0002
Number of Individuals Covered782
Insurance policy start date2011-05-01
Insurance policy end date2012-04-30
Total amount of commissions paid to insurance brokerUSD $5,075
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Dental Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
MEDICAL MUTUAL OF OHIO (National Association of Insurance Commissioners NAIC id number: 29076 )
Policy contract number
Policy instance 2
Number of Individuals Covered330
Insurance policy start date2011-07-01
Insurance policy end date2012-04-30
Total amount of commissions paid to insurance brokerUSD $33,000
Total amount of fees paid to insurance companyUSD $21,009
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Health Insurance Welfare BenefitYes
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 numberG000AJNW
Policy instance 4
Insurance contract or identification numberG000AJNW
Number of Individuals Covered318
Insurance policy start date2011-10-01
Insurance policy end date2012-05-01
Total amount of commissions paid to insurance brokerUSD $5,323
Total amount of fees paid to insurance companyUSD $8,923
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Other welfare benefits providedAD&D AND LIFE
Welfare Benefit Premiums Paid to CarrierUSD $16,422
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
CONSUMERS LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62375 )
Policy contract number954167
Policy instance 3
Insurance contract or identification number954167
Number of Individuals Covered355
Insurance policy start date2011-05-01
Insurance policy end date2011-06-30
Total amount of commissions paid to insurance brokerUSD $7,100
Total amount of fees paid to insurance companyUSD $129
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Health Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 )
Policy contract number9794-0001,0002
Policy instance 1
Insurance contract or identification number9794-0001,0002
Number of Individuals Covered850
Insurance policy start date2010-05-01
Insurance policy end date2011-04-30
Total amount of commissions paid to insurance brokerUSD $5,125
Total amount of fees paid to insurance companyUSD $23,593
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Dental Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
CONSUMERS LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62375 )
Policy contract number954167
Policy instance 3
Insurance contract or identification number954167
Number of Individuals Covered357
Insurance policy start date2010-05-01
Insurance policy end date2011-04-30
Total amount of commissions paid to insurance brokerUSD $48,109
Total amount of fees paid to insurance companyUSD $3,236
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Health Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )
Policy contract number138868
Policy instance 4
Insurance contract or identification number138868
Number of Individuals Covered1
Insurance policy start date2010-05-01
Insurance policy end date2011-05-01
Total amount of commissions paid to insurance brokerUSD $67
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Temporary Disability Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number574611,580592
Policy instance 2
Insurance contract or identification number574611,580592
Number of Individuals Covered342
Insurance policy start date2010-05-01
Insurance policy end date2011-04-30
Total amount of commissions paid to insurance brokerUSD $3,950
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Other welfare benefits providedAD&D AND LIFE
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No

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