RITSEMA ASSOCIATES has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan RITSEMA ASSOCIATES WELFARE BENEFIT PLAN
| Measure | Date | Value |
|---|
| 2022: RITSEMA ASSOCIATES WELFARE BENEFIT PLAN 2022 401k membership |
|---|
| Total participants, beginning-of-year | 2022-06-01 | 120 |
| Total number of active participants reported on line 7a of the Form 5500 | 2022-06-01 | 100 |
| Number of retired or separated participants receiving benefits | 2022-06-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2022-06-01 | 0 |
| Total of all active and inactive participants | 2022-06-01 | 100 |
| Number of employers contributing to the scheme | 2022-06-01 | 0 |
| 2021: RITSEMA ASSOCIATES WELFARE BENEFIT PLAN 2021 401k membership |
|---|
| Total participants, beginning-of-year | 2021-06-01 | 115 |
| Total number of active participants reported on line 7a of the Form 5500 | 2021-06-01 | 120 |
| Number of retired or separated participants receiving benefits | 2021-06-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2021-06-01 | 0 |
| Total of all active and inactive participants | 2021-06-01 | 120 |
| Number of employers contributing to the scheme | 2021-06-01 | 0 |
| 2020: RITSEMA ASSOCIATES WELFARE BENEFIT PLAN 2020 401k membership |
|---|
| Total participants, beginning-of-year | 2020-06-01 | 118 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-06-01 | 115 |
| Number of retired or separated participants receiving benefits | 2020-06-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2020-06-01 | 0 |
| Total of all active and inactive participants | 2020-06-01 | 115 |
| Number of employers contributing to the scheme | 2020-06-01 | 0 |
| 2019: RITSEMA ASSOCIATES WELFARE BENEFIT PLAN 2019 401k membership |
|---|
| Total participants, beginning-of-year | 2019-06-01 | 122 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-06-01 | 118 |
| Number of retired or separated participants receiving benefits | 2019-06-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2019-06-01 | 0 |
| Total of all active and inactive participants | 2019-06-01 | 118 |
| Number of employers contributing to the scheme | 2019-06-01 | 0 |
| 2018: RITSEMA ASSOCIATES WELFARE BENEFIT PLAN 2018 401k membership |
|---|
| Total participants, beginning-of-year | 2018-06-01 | 106 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-06-01 | 122 |
| Number of retired or separated participants receiving benefits | 2018-06-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2018-06-01 | 0 |
| Total of all active and inactive participants | 2018-06-01 | 122 |
| Number of employers contributing to the scheme | 2018-06-01 | 0 |
| 2013: RITSEMA ASSOCIATES WELFARE BENEFIT PLAN 2013 401k membership |
|---|
| Total participants, beginning-of-year | 2013-06-01 | 74 |
| Total number of active participants reported on line 7a of the Form 5500 | 2013-06-01 | 88 |
| Number of retired or separated participants receiving benefits | 2013-06-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2013-06-01 | 1 |
| Total of all active and inactive participants | 2013-06-01 | 89 |
| 2012: RITSEMA ASSOCIATES WELFARE BENEFIT PLAN 2012 401k membership |
|---|
| Total participants, beginning-of-year | 2012-06-01 | 162 |
| Total number of active participants reported on line 7a of the Form 5500 | 2012-06-01 | 215 |
| Number of retired or separated participants receiving benefits | 2012-06-01 | 7 |
| Number of other retired or separated participants entitled to future benefits | 2012-06-01 | 2 |
| Total of all active and inactive participants | 2012-06-01 | 224 |
| 2011: RITSEMA ASSOCIATES WELFARE BENEFIT PLAN 2011 401k membership |
|---|
| Total participants, beginning-of-year | 2011-06-01 | 154 |
| Total number of active participants reported on line 7a of the Form 5500 | 2011-06-01 | 160 |
| Number of retired or separated participants receiving benefits | 2011-06-01 | 2 |
| Number of other retired or separated participants entitled to future benefits | 2011-06-01 | 0 |
| Total of all active and inactive participants | 2011-06-01 | 162 |
| 2010: RITSEMA ASSOCIATES WELFARE BENEFIT PLAN 2010 401k membership |
|---|
| Total participants, beginning-of-year | 2010-06-01 | 137 |
| Total number of active participants reported on line 7a of the Form 5500 | 2010-06-01 | 130 |
| Number of retired or separated participants receiving benefits | 2010-06-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2010-06-01 | 0 |
| Total of all active and inactive participants | 2010-06-01 | 130 |
| 2009: RITSEMA ASSOCIATES WELFARE BENEFIT PLAN 2009 401k membership |
|---|
| Total participants, beginning-of-year | 2009-06-01 | 177 |
| Total number of active participants reported on line 7a of the Form 5500 | 2009-06-01 | 134 |
| Number of retired or separated participants receiving benefits | 2009-06-01 | 2 |
| Number of other retired or separated participants entitled to future benefits | 2009-06-01 | 2 |
| Total of all active and inactive participants | 2009-06-01 | 138 |
| 2022: RITSEMA ASSOCIATES WELFARE BENEFIT PLAN 2022 form 5500 responses |
|---|
| 2022-06-01 | Type of plan entity | Single employer plan |
| 2022-06-01 | Plan funding arrangement – Insurance | Yes |
| 2022-06-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2022-06-01 | Plan benefit arrangement – Insurance | Yes |
| 2022-06-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2021: RITSEMA ASSOCIATES WELFARE BENEFIT PLAN 2021 form 5500 responses |
|---|
| 2021-06-01 | Type of plan entity | Single employer plan |
| 2021-06-01 | Plan funding arrangement – Insurance | Yes |
| 2021-06-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2021-06-01 | Plan benefit arrangement – Insurance | Yes |
| 2021-06-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2020: RITSEMA ASSOCIATES WELFARE BENEFIT PLAN 2020 form 5500 responses |
|---|
| 2020-06-01 | Type of plan entity | Single employer plan |
| 2020-06-01 | Plan funding arrangement – Insurance | Yes |
| 2020-06-01 | Plan benefit arrangement – Insurance | Yes |
| 2019: RITSEMA ASSOCIATES WELFARE BENEFIT PLAN 2019 form 5500 responses |
|---|
| 2019-06-01 | Type of plan entity | Single employer plan |
| 2019-06-01 | Plan funding arrangement – Insurance | Yes |
| 2019-06-01 | Plan benefit arrangement – Insurance | Yes |
| 2018: RITSEMA ASSOCIATES WELFARE BENEFIT PLAN 2018 form 5500 responses |
|---|
| 2018-06-01 | Type of plan entity | Single employer plan |
| 2018-06-01 | Plan funding arrangement – Insurance | Yes |
| 2018-06-01 | Plan benefit arrangement – Insurance | Yes |
| 2013: RITSEMA ASSOCIATES WELFARE BENEFIT PLAN 2013 form 5500 responses |
|---|
| 2013-06-01 | Type of plan entity | Single employer plan |
| 2013-06-01 | Submission has been amended | No |
| 2013-06-01 | This submission is the final filing | No |
| 2013-06-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2013-06-01 | Plan is a collectively bargained plan | No |
| 2013-06-01 | Plan funding arrangement – Insurance | Yes |
| 2013-06-01 | Plan benefit arrangement – Insurance | Yes |
| 2012: RITSEMA ASSOCIATES WELFARE BENEFIT PLAN 2012 form 5500 responses |
|---|
| 2012-06-01 | Type of plan entity | Single employer plan |
| 2012-06-01 | Submission has been amended | No |
| 2012-06-01 | This submission is the final filing | No |
| 2012-06-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2012-06-01 | Plan is a collectively bargained plan | No |
| 2012-06-01 | Plan funding arrangement – Insurance | Yes |
| 2012-06-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2012-06-01 | Plan benefit arrangement – Insurance | Yes |
| 2012-06-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2011: RITSEMA ASSOCIATES WELFARE BENEFIT PLAN 2011 form 5500 responses |
|---|
| 2011-06-01 | Type of plan entity | Single employer plan |
| 2011-06-01 | Submission has been amended | No |
| 2011-06-01 | This submission is the final filing | No |
| 2011-06-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2011-06-01 | Plan is a collectively bargained plan | No |
| 2011-06-01 | Plan funding arrangement – Insurance | Yes |
| 2011-06-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2011-06-01 | Plan benefit arrangement – Insurance | Yes |
| 2011-06-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2010: RITSEMA ASSOCIATES WELFARE BENEFIT PLAN 2010 form 5500 responses |
|---|
| 2010-06-01 | Type of plan entity | Single employer plan |
| 2010-06-01 | Submission has been amended | No |
| 2010-06-01 | This submission is the final filing | No |
| 2010-06-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2010-06-01 | Plan is a collectively bargained plan | No |
| 2010-06-01 | Plan funding arrangement – Insurance | Yes |
| 2010-06-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2010-06-01 | Plan benefit arrangement – Insurance | Yes |
| 2010-06-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2009: RITSEMA ASSOCIATES WELFARE BENEFIT PLAN 2009 form 5500 responses |
|---|
| 2009-06-01 | Type of plan entity | Single employer plan |
| 2009-06-01 | Submission has been amended | No |
| 2009-06-01 | This submission is the final filing | No |
| 2009-06-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2009-06-01 | Plan is a collectively bargained plan | No |
| 2009-06-01 | Plan funding arrangement – Insurance | Yes |
| 2009-06-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2009-06-01 | Plan benefit arrangement – Insurance | Yes |
| 2009-06-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLTD0ASLQ |
| Policy instance | 6 |
| Insurance contract or identification number | GLTD0ASLQ | | Number of Individuals Covered | 122 | | Insurance policy start date | 2022-06-01 | | Insurance policy end date | 2023-05-31 | | Total amount of commissions paid to insurance broker | USD $6,457 | | Total amount of fees paid to insurance company | USD $3,189 | | 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 | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $51,376 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,457 | | Amount paid for insurance broker fees | 3189 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| PINE REST CHRISTIAN MENTAL HEALTH SERVICES (National Association of Insurance Commissioners NAIC id number: 62142 ) |
| Policy contract number | 00 |
| Policy instance | 5 |
| Insurance contract or identification number | 00 | | Number of Individuals Covered | 75 | | Insurance policy start date | 2022-06-01 | | Insurance policy end date | 2023-05-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | EMPLOYEE ASSISTANCE PROGRAM | | Welfare Benefit Premiums Paid to Carrier | USD $1,450 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 10328781001 |
| Policy instance | 4 |
| Insurance contract or identification number | 10328781001 | | Number of Individuals Covered | 0 | | Insurance policy start date | 2022-06-01 | | Insurance policy end date | 2023-05-31 | | 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 $0 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 ) |
| Policy contract number | 0010621 |
| Policy instance | 3 |
| Insurance contract or identification number | 0010621 | | Number of Individuals Covered | 184 | | Insurance policy start date | 2022-06-01 | | Insurance policy end date | 2023-05-31 | | Total amount of commissions paid to insurance broker | USD $5,155 | | Total amount of fees paid to insurance company | USD $0 | | 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 $5,155 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| BLUE CARE NETWORK OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 95610 ) |
| Policy contract number | 177355 |
| Policy instance | 2 |
| Insurance contract or identification number | 177355 | | Number of Individuals Covered | 201 | | Insurance policy start date | 2022-06-01 | | Insurance policy end date | 2023-05-31 | | Total amount of commissions paid to insurance broker | USD $42,518 | | Total amount of fees paid to insurance company | USD $1,038 | | Health 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 $42,518 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Additional information about fees paid to insurance broker | FEES AND OTHER COMMISSIONS |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 10001491001 |
| Policy instance | 1 |
| Insurance contract or identification number | 10001491001 | | Number of Individuals Covered | 136 | | Insurance policy start date | 2022-06-01 | | Insurance policy end date | 2023-05-31 | | Total amount of commissions paid to insurance broker | USD $876 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $8,856 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $876 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| BLUE CARE NETWORK OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 95610 ) |
| Policy contract number | 177355 |
| Policy instance | 1 |
| Insurance contract or identification number | 177355 | | Number of Individuals Covered | 168 | | Insurance policy start date | 2021-06-01 | | Insurance policy end date | 2022-05-31 | | Total amount of commissions paid to insurance broker | USD $39,745 | | Total amount of fees paid to insurance company | USD $977 | | Health 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 $39,745 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Additional information about fees paid to insurance broker | FEES AND OTHER COMMISSIONS |
|
| DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 ) |
| Policy contract number | 0010621 |
| Policy instance | 2 |
| Insurance contract or identification number | 0010621 | | Number of Individuals Covered | 153 | | Insurance policy start date | 2021-06-01 | | Insurance policy end date | 2022-05-31 | | Total amount of commissions paid to insurance broker | USD $4,248 | | Total amount of fees paid to insurance company | USD $0 | | 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 $4,248 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| PINE REST CHRISTIAN MENTAL HEALTH SERVICES (National Association of Insurance Commissioners NAIC id number: 62142 ) |
| Policy contract number | 00 |
| Policy instance | 3 |
| Insurance contract or identification number | 00 | | Number of Individuals Covered | 120 | | Insurance policy start date | 2021-06-01 | | Insurance policy end date | 2022-05-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | EMPLOYEE ASSISTANCE PROGRAM | | Welfare Benefit Premiums Paid to Carrier | USD $2,260 | | 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 | GLTD0ASLQ |
| Policy instance | 4 |
| Insurance contract or identification number | GLTD0ASLQ | | Number of Individuals Covered | 110 | | Insurance policy start date | 2021-06-01 | | Insurance policy end date | 2022-05-31 | | Total amount of commissions paid to insurance broker | USD $6,249 | | Total amount of fees paid to insurance company | USD $1,876 | | 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 | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $48,551 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,249 | | Amount paid for insurance broker fees | 1876 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 10001491001 |
| Policy instance | 5 |
| Insurance contract or identification number | 10001491001 | | Number of Individuals Covered | 264 | | Insurance policy start date | 2021-06-01 | | Insurance policy end date | 2022-05-31 | | Total amount of commissions paid to insurance broker | USD $1,022 | | Total amount of fees paid to insurance company | USD $0 | | 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 | | Welfare Benefit Premiums Paid to Carrier | USD $10,073 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,022 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | SGM605208 |
| Policy instance | 5 |
| Insurance contract or identification number | SGM605208 | | Number of Individuals Covered | 115 | | Insurance policy start date | 2020-06-01 | | Insurance policy end date | 2021-05-31 | | Total amount of commissions paid to insurance broker | USD $726 | | Total amount of fees paid to insurance company | USD $96 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $6,837 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $726 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Additional information about fees paid to insurance broker | OVERRIDE |
|
| BLUE CARE NETWORK OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 95610 ) |
| Policy contract number | 177355 |
| Policy instance | 4 |
| Insurance contract or identification number | 177355 | | Number of Individuals Covered | 169 | | Insurance policy start date | 2020-06-01 | | Insurance policy end date | 2021-05-31 | | Total amount of commissions paid to insurance broker | USD $34,311 | | Total amount of fees paid to insurance company | USD $0 | | Health 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 $30,698 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 0 |
|
| BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 ) |
| Policy contract number | 177355 |
| Policy instance | 3 |
| Insurance contract or identification number | 177355 | | Number of Individuals Covered | 137 | | Insurance policy start date | 2020-06-01 | | Insurance policy end date | 2021-05-31 | | Total amount of commissions paid to insurance broker | USD $3,029 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | 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 $2,739 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 0 |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 10001491001 |
| Policy instance | 2 |
| Insurance contract or identification number | 10001491001 | | Number of Individuals Covered | 117 | | Insurance policy start date | 2020-06-01 | | Insurance policy end date | 2021-05-31 | | Total amount of commissions paid to insurance broker | USD $735 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $6,741 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $667 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 0 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLTD0ASLQ |
| Policy instance | 1 |
| Insurance contract or identification number | GLTD0ASLQ | | Number of Individuals Covered | 115 | | Insurance policy start date | 2020-06-01 | | Insurance policy end date | 2021-05-31 | | Total amount of commissions paid to insurance broker | USD $3,583 | | Total amount of fees paid to insurance company | USD $1,763 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $31,662 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,464 | | Amount paid for insurance broker fees | 1763 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 10001491001 |
| Policy instance | 2 |
| Insurance contract or identification number | 10001491001 | | Number of Individuals Covered | 109 | | Insurance policy start date | 2019-06-01 | | Insurance policy end date | 2020-05-31 | | Total amount of commissions paid to insurance broker | USD $658 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $6,682 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $658 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 ) |
| Policy contract number | 177355 |
| Policy instance | 3 |
| Insurance contract or identification number | 177355 | | Number of Individuals Covered | 134 | | Insurance policy start date | 2019-06-01 | | Insurance policy end date | 2020-05-31 | | Total amount of commissions paid to insurance broker | USD $3,100 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | 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 $3,100 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| BLUE CARE NETWORK OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 95610 ) |
| Policy contract number | 177355 |
| Policy instance | 4 |
| Insurance contract or identification number | 177355 | | Number of Individuals Covered | 163 | | Insurance policy start date | 2019-06-01 | | Insurance policy end date | 2020-05-31 | | Total amount of commissions paid to insurance broker | USD $30,962 | | Total amount of fees paid to insurance company | USD $0 | | Health 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 $30,962 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | SGM605208 |
| Policy instance | 5 |
| Insurance contract or identification number | SGM605208 | | Number of Individuals Covered | 118 | | Insurance policy start date | 2019-06-01 | | Insurance policy end date | 2020-05-31 | | Total amount of commissions paid to insurance broker | USD $2,185 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $20,595 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $2,185 | | 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 | GLTD0ASLQ |
| Policy instance | 1 |
| Insurance contract or identification number | GLTD0ASLQ | | Number of Individuals Covered | 118 | | Insurance policy start date | 2019-06-01 | | Insurance policy end date | 2020-05-31 | | Total amount of commissions paid to insurance broker | USD $3,319 | | Total amount of fees paid to insurance company | USD $966 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $26,384 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,319 | | Amount paid for insurance broker fees | 966 | | 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 | GLTD0ASLQ |
| Policy instance | 1 |
| Insurance contract or identification number | GLTD0ASLQ | | Number of Individuals Covered | 122 | | Insurance policy start date | 2018-06-01 | | Insurance policy end date | 2019-05-31 | | Total amount of commissions paid to insurance broker | USD $3,350 | | Total amount of fees paid to insurance company | USD $829 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $27,005 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,025 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION |
|
| BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 ) |
| Policy contract number | 177355 |
| Policy instance | 3 |
| Insurance contract or identification number | 177355 | | Number of Individuals Covered | 137 | | Insurance policy start date | 2018-06-01 | | Insurance policy end date | 2019-05-31 | | Total amount of commissions paid to insurance broker | USD $3,198 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | 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 $2,976 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
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| BLUE CARE NETWORK OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 95610 ) |
| Policy contract number | 177355 |
| Policy instance | 4 |
| Insurance contract or identification number | 177355 | | Number of Individuals Covered | 161 | | Insurance policy start date | 2018-06-01 | | Insurance policy end date | 2019-05-31 | | Total amount of commissions paid to insurance broker | USD $38,358 | | Total amount of fees paid to insurance company | USD $944 | | Health 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 $33,917 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Additional information about fees paid to insurance broker | FEES AND OTHER COMMISSIONS |
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| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | SOK600028 |
| Policy instance | 5 |
| Insurance contract or identification number | SOK600028 | | Number of Individuals Covered | 122 | | Insurance policy start date | 2018-06-01 | | Insurance policy end date | 2019-05-31 | | Total amount of commissions paid to insurance broker | USD $1,851 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $17,314 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $1,680 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
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| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 10001491001 |
| Policy instance | 2 |
| Insurance contract or identification number | 10001491001 | | Number of Individuals Covered | 97 | | Insurance policy start date | 2018-06-01 | | Insurance policy end date | 2019-05-31 | | Total amount of commissions paid to insurance broker | USD $606 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $6,090 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $555 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
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