A.D. TRANSPORT EXPRESS, INC. has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan A.D. TRANSPORT EMPLOYEE WELFARE BENEFIT PLAN
401k plan membership statisitcs for A.D. TRANSPORT EMPLOYEE WELFARE BENEFIT PLAN
| 2022: A.D. TRANSPORT EMPLOYEE WELFARE BENEFIT PLAN 2022 form 5500 responses |
|---|
| 2022-01-01 | Type of plan entity | Single employer plan |
| 2022-01-01 | Plan funding arrangement – Insurance | Yes |
| 2022-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2022-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2022-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2021: A.D. TRANSPORT EMPLOYEE WELFARE BENEFIT PLAN 2021 form 5500 responses |
|---|
| 2021-01-01 | Type of plan entity | Single employer plan |
| 2021-01-01 | Submission has been amended | No |
| 2021-01-01 | This submission is the final filing | No |
| 2021-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2021-01-01 | Plan is a collectively bargained plan | No |
| 2021-01-01 | Plan funding arrangement – Insurance | Yes |
| 2021-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2020: A.D. TRANSPORT EMPLOYEE WELFARE BENEFIT PLAN 2020 form 5500 responses |
|---|
| 2020-01-01 | Type of plan entity | Single employer plan |
| 2020-01-01 | Submission has been amended | No |
| 2020-01-01 | This submission is the final filing | No |
| 2020-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2020-01-01 | Plan is a collectively bargained plan | No |
| 2020-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2020-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2019: A.D. TRANSPORT EMPLOYEE WELFARE BENEFIT PLAN 2019 form 5500 responses |
|---|
| 2019-01-01 | Type of plan entity | Single employer plan |
| 2019-01-01 | Submission has been amended | No |
| 2019-01-01 | This submission is the final filing | No |
| 2019-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2019-01-01 | Plan is a collectively bargained plan | No |
| 2019-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2019-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2019-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2018: A.D. TRANSPORT EMPLOYEE WELFARE BENEFIT PLAN 2018 form 5500 responses |
|---|
| 2018-01-01 | Type of plan entity | Single employer plan |
| 2018-01-01 | Submission has been amended | No |
| 2018-01-01 | This submission is the final filing | No |
| 2018-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2018-01-01 | Plan is a collectively bargained plan | No |
| 2018-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2018-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2018-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2017: A.D. TRANSPORT EMPLOYEE WELFARE BENEFIT PLAN 2017 form 5500 responses |
|---|
| 2017-01-01 | Type of plan entity | Single employer plan |
| 2017-01-01 | Submission has been amended | No |
| 2017-01-01 | This submission is the final filing | No |
| 2017-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2017-01-01 | Plan is a collectively bargained plan | No |
| 2017-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2017-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2017-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2016: A.D. TRANSPORT EMPLOYEE WELFARE BENEFIT PLAN 2016 form 5500 responses |
|---|
| 2016-01-01 | Type of plan entity | Single employer plan |
| 2016-01-01 | Submission has been amended | No |
| 2016-01-01 | This submission is the final filing | No |
| 2016-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2016-01-01 | Plan is a collectively bargained plan | No |
| 2016-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2016-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2016-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2015: A.D. TRANSPORT EMPLOYEE WELFARE BENEFIT PLAN 2015 form 5500 responses |
|---|
| 2015-01-01 | Type of plan entity | Single employer plan |
| 2015-01-01 | Submission has been amended | No |
| 2015-01-01 | This submission is the final filing | No |
| 2015-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2015-01-01 | Plan is a collectively bargained plan | No |
| 2015-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2015-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2015-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2014: A.D. TRANSPORT EMPLOYEE WELFARE BENEFIT PLAN 2014 form 5500 responses |
|---|
| 2014-01-01 | Type of plan entity | Single employer plan |
| 2014-01-01 | Submission has been amended | No |
| 2014-01-01 | This submission is the final filing | No |
| 2014-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2014-01-01 | Plan is a collectively bargained plan | No |
| 2014-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2014-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2013: A.D. TRANSPORT EMPLOYEE WELFARE BENEFIT PLAN 2013 form 5500 responses |
|---|
| 2013-01-01 | Type of plan entity | Single employer plan |
| 2013-01-01 | Submission has been amended | No |
| 2013-01-01 | This submission is the final filing | No |
| 2013-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2013-01-01 | Plan is a collectively bargained plan | No |
| 2013-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2013-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2012: A.D. TRANSPORT EMPLOYEE WELFARE BENEFIT PLAN 2012 form 5500 responses |
|---|
| 2012-01-01 | Type of plan entity | Single employer plan |
| 2012-01-01 | Submission has been amended | No |
| 2012-01-01 | This submission is the final filing | No |
| 2012-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2012-01-01 | Plan is a collectively bargained plan | No |
| 2012-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2012-01-01 | Plan benefit arrangement – Insurance | Yes |
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 576498 |
| Policy instance | 3 |
| Insurance contract or identification number | 576498 | | Number of Individuals Covered | 352 | | Insurance policy start date | 2021-08-01 | | Insurance policy end date | 2022-07-31 | | Total amount of commissions paid to insurance broker | USD $4,995 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | ACCIDENT, CRITICAL ILLNESS, HOSPITAL | | Welfare Benefit Premiums Paid to Carrier | USD $127,427 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,653 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 ) |
| Policy contract number | 1097036 |
| Policy instance | 2 |
| Insurance contract or identification number | 1097036 | | Number of Individuals Covered | 801 | | Insurance policy start date | 2021-08-01 | | Insurance policy end date | 2022-07-31 | | Total amount of commissions paid to insurance broker | USD $12,935 | | Total amount of fees paid to insurance company | USD $12,139 | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | EMPLOYEE ASSISTANCE PROGRAM, CRITICAL ILLNESS | | Welfare Benefit Premiums Paid to Carrier | USD $635,288 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,826 | | Amount paid for insurance broker fees | 9397 | | Additional information about fees paid to insurance broker | BONUS | | Insurance broker organization code? | 3 |
|
| PRIORITY HEALTH (National Association of Insurance Commissioners NAIC id number: 12208 ) |
| Policy contract number | 796401 |
| Policy instance | 1 |
| Insurance contract or identification number | 796401 | | Number of Individuals Covered | 456 | | Insurance policy start date | 2021-08-01 | | Insurance policy end date | 2022-07-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $3,700,947 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 ) |
| Policy contract number | 125222 |
| Policy instance | 1 |
| Insurance contract or identification number | 125222 | | Number of Individuals Covered | 222 | | Insurance policy start date | 2020-08-01 | | Insurance policy end date | 2021-07-31 | | Total amount of commissions paid to insurance broker | USD $55,338 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 $0 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $46,653 | | Insurance broker organization code? | 3 |
|
| TOTAL HEALTH CARE USA INC (National Association of Insurance Commissioners NAIC id number: 12326 ) |
| Policy contract number | T60043 |
| Policy instance | 2 |
| Insurance contract or identification number | T60043 | | Number of Individuals Covered | 430 | | Insurance policy start date | 2020-08-01 | | Insurance policy end date | 2021-07-31 | | Total amount of commissions paid to insurance broker | USD $1,897 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | 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 | | Welfare Benefit Premiums Paid to Carrier | USD $1,966,769 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,897 | | Insurance broker organization code? | 3 |
|
| PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 ) |
| Policy contract number | 1097036 |
| Policy instance | 3 |
| Insurance contract or identification number | 1097036 | | Number of Individuals Covered | 770 | | Insurance policy start date | 2020-08-01 | | Insurance policy end date | 2021-07-31 | | Total amount of commissions paid to insurance broker | USD $48,326 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | 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 $563,123 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $48,326 | | Insurance broker organization code? | 3 |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 00576498 |
| Policy instance | 4 |
| Insurance contract or identification number | 00576498 | | Number of Individuals Covered | 311 | | Insurance policy start date | 2020-08-01 | | Insurance policy end date | 2021-07-31 | | Total amount of commissions paid to insurance broker | USD $29,408 | | Total amount of fees paid to insurance company | USD $5,465 | | 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 CRITICAL ILLNESS, VOLUNTARY HOSPITAL INDEMNITY | | 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 $252,154 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $29,408 | | Amount paid for insurance broker fees | 5465 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker organization code? | 3 |
|
| PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 ) |
| Policy contract number | 1097036 |
| Policy instance | 3 |
| Insurance contract or identification number | 1097036 | | Number of Individuals Covered | 837 | | Insurance policy start date | 2019-08-01 | | Insurance policy end date | 2020-07-31 | | Total amount of commissions paid to insurance broker | USD $68,341 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | 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 $599,280 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $57,239 | | Insurance broker organization code? | 3 |
|
| NATIONWIDE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 66869 ) |
| Policy contract number | 1347 |
| Policy instance | 2 |
| Insurance contract or identification number | 1347 | | Number of Individuals Covered | 46 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $7,855 | | Total amount of fees paid to insurance company | USD $942 | | 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 $55,876 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,415 | | Amount paid for insurance broker fees | 942 | | Additional information about fees paid to insurance broker | BROKER FEE AGREEMENT | | Insurance broker organization code? | 3 |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 0744323 |
| Policy instance | 1 |
| Insurance contract or identification number | 0744323 | | Number of Individuals Covered | 240 | | Insurance policy start date | 2019-08-01 | | Insurance policy end date | 2020-07-31 | | Total amount of commissions paid to insurance broker | USD $8,395 | | Total amount of fees paid to insurance company | USD $17,326 | | 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 $1,738,814 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,395 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Additional information about fees paid to insurance broker | SERVICE FEE AGREEMENT |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 0744323 |
| Policy instance | 1 |
| Insurance contract or identification number | 0744323 | | Number of Individuals Covered | 163 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of fees paid to insurance company | USD $51,552 | | 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 $1,114,076 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 54 | | Additional information about fees paid to insurance broker | SERVICE FEE AGREEMENT | | Insurance broker organization code? | 3 |
|
| NATIONWIDE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 66869 ) |
| Policy contract number | 1347 |
| Policy instance | 2 |
| Insurance contract or identification number | 1347 | | Number of Individuals Covered | 67 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $10,020 | | Total amount of fees paid to insurance company | USD $6,912 | | 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 $65,141 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $921 | | Amount paid for insurance broker fees | 192 | | Additional information about fees paid to insurance broker | BROKER FEE | | Insurance broker organization code? | 3 |
|
| PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 ) |
| Policy contract number | 109/036 |
| Policy instance | 3 |
| Insurance contract or identification number | 109/036 | | Number of Individuals Covered | 818 | | Insurance policy start date | 2018-08-01 | | Insurance policy end date | 2019-07-31 | | Total amount of commissions paid to insurance broker | USD $62,698 | | Total amount of fees paid to insurance company | USD $59,637 | | 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 | Yes | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | 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 $628,197 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 17008 | | Additional information about fees paid to insurance broker | BONUS | | Insurance broker organization code? | 3 | | Commission paid to Insurance Broker | USD $62,698 |
|
| PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 ) |
| Policy contract number | 1097036 |
| Policy instance | 3 |
| Insurance contract or identification number | 1097036 | | Number of Individuals Covered | 818 | | Insurance policy start date | 2018-08-01 | | Insurance policy end date | 2019-07-31 | | Total amount of commissions paid to insurance broker | USD $62,698 | | Total amount of fees paid to insurance company | USD $59,637 | | 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 | Yes | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | 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 $628,197 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 17008 | | Additional information about fees paid to insurance broker | BONUS | | Insurance broker organization code? | 3 | | Commission paid to Insurance Broker | USD $62,698 |
|
| NATIONWIDE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 66869 ) |
| Policy contract number | 1347 |
| Policy instance | 4 |
| Insurance contract or identification number | 1347 | | Number of Individuals Covered | 89 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $15,083 | | Total amount of fees paid to insurance company | USD $7,524 | | 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 $88,698 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $3,975 | | Amount paid for insurance broker fees | 573 | | Additional information about fees paid to insurance broker | SERVICE FEE AGREEMENT | | Insurance broker organization code? | 3 |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 0744323 |
| Policy instance | 3 |
| Insurance contract or identification number | 0744323 | | Number of Individuals Covered | 148 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $5,713 | | Total amount of fees paid to insurance company | USD $64,531 | | 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 $1,860,891 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $3,774 | | Amount paid for insurance broker fees | 16160 | | Additional information about fees paid to insurance broker | SERVICE FEE AGREEMENT | | Insurance broker organization code? | 3 |
|
| DENCAP DENTAL PLANS (National Association of Insurance Commissioners NAIC id number: 52025 ) |
| Policy contract number | 000450 |
| Policy instance | 2 |
| Insurance contract or identification number | 000450 | | Number of Individuals Covered | 113 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-07-31 | | Total amount of commissions paid to insurance broker | USD $2,269 | | 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 | Yes | | 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 $21,567 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $486 | | Insurance broker organization code? | 3 |
|
| TOTAL HEALTH CARE USA INC (National Association of Insurance Commissioners NAIC id number: 12326 ) |
| Policy contract number | M60043 |
| Policy instance | 1 |
| Insurance contract or identification number | M60043 | | Number of Individuals Covered | 535 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $63,434 | | 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 | | Welfare Benefit Premiums Paid to Carrier | USD $2,330,577 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $47,894 | | Insurance broker organization code? | 3 |
|
| TOTAL HEALTH CARE USA INC (National Association of Insurance Commissioners NAIC id number: 12326 ) |
| Policy contract number | M60043 |
| Policy instance | 1 |
| Insurance contract or identification number | M60043 | | Number of Individuals Covered | 536 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $61,586 | | 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 | | Welfare Benefit Premiums Paid to Carrier | USD $2,183,511 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $61,586 | | Insurance broker organization code? | 3 | | Insurance broker name | MARK PONDER |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 0744323 |
| Policy instance | 2 |
| Insurance contract or identification number | 0744323 | | Number of Individuals Covered | 778 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $8,042 | | Total amount of fees paid to insurance company | USD $70,075 | | 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 $1,884,421 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $8,041 | | Amount paid for insurance broker fees | 70075 | | Additional information about fees paid to insurance broker | SERVICE FEE AGREEMENT | | Insurance broker organization code? | 3 | | Insurance broker name | MARK S. PONDER |
|
| DENCAP DENTAL PLANS (National Association of Insurance Commissioners NAIC id number: 52025 ) |
| Policy contract number | 000450 |
| Policy instance | 4 |
| Insurance contract or identification number | 000450 | | Number of Individuals Covered | 113 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $4,337 | | 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 | Yes | | 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 $43,365 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $4,337 | | Insurance broker organization code? | 3 | | Insurance broker name | MARK S. PONDER |
|
| NATIONWIDE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 66869 ) |
| Policy contract number | 1347 |
| Policy instance | 3 |
| Insurance contract or identification number | 1347 | | Number of Individuals Covered | 104 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $23,129 | | Total amount of fees paid to insurance company | USD $10,746 | | 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 $125,036 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $10,984 | | Amount paid for insurance broker fees | 1791 | | Additional information about fees paid to insurance broker | BROKER FEE | | Insurance broker organization code? | 3 | | Insurance broker name | FRINGE INSURANCE BENEFITS, INC. |
|
| COMPANION LIFE (National Association of Insurance Commissioners NAIC id number: 77828 ) |
| Policy contract number | CXL00116 |
| Policy instance | 5 |
| Insurance contract or identification number | CXL00116 | | Number of Individuals Covered | 40 | | Insurance policy start date | 2015-05-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $903 | | 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 $1,355 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $903 | | Insurance broker organization code? | 3 | | Insurance broker name | RGI, LLC |
|
| COMPANION LIFE (National Association of Insurance Commissioners NAIC id number: 77828 ) |
| Policy contract number | C7196 |
| Policy instance | 4 |
| Insurance contract or identification number | C7196 | | Number of Individuals Covered | 155 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $11,889 | | 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 $118,895 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $11,889 | | Insurance broker organization code? | 3 | | Insurance broker name | JOHN BRODERSEN |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 0744323 |
| Policy instance | 3 |
| Insurance contract or identification number | 0744323 | | Number of Individuals Covered | 751 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $8,147 | | 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 | Yes | | 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 | | Welfare Benefit Premiums Paid to Carrier | USD $62,264 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,147 | | Insurance broker organization code? | 3 | | Insurance broker name | MARK S. PONDER |
|
| DENCAP DENTAL PLANS (National Association of Insurance Commissioners NAIC id number: 52025 ) |
| Policy contract number | 000450 |
| Policy instance | 2 |
| Insurance contract or identification number | 000450 | | Number of Individuals Covered | 137 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $5,226 | | 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 | 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 $52,265 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,226 | | Insurance broker organization code? | 3 | | Insurance broker name | MARK S. PONDER |
|
| TOTAL HEALTH CARE USA INC (National Association of Insurance Commissioners NAIC id number: 12326 ) |
| Policy contract number | M60043 |
| Policy instance | 1 |
| Insurance contract or identification number | M60043 | | Number of Individuals Covered | 554 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $60,096 | | 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 | | Welfare Benefit Premiums Paid to Carrier | USD $2,167,222 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $60,096 | | Insurance broker organization code? | 3 | | Insurance broker name | HEALTH INSURANCE ADVISORS |
|
| TOTAL HEALTH CARE USA INC (National Association of Insurance Commissioners NAIC id number: 12326 ) |
| Policy contract number | M60043 |
| Policy instance | 1 |
| Insurance contract or identification number | M60043 | | Number of Individuals Covered | 560 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $64,120 | | 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 | | Welfare Benefit Premiums Paid to Carrier | USD $2,419,174 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $64,120 | | Insurance broker organization code? | 3 | | Insurance broker name | HEALTH INSURANCE ADVISORS |
|
| AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 ) |
| Policy contract number | V0081 |
| Policy instance | 3 |
| Insurance contract or identification number | V0081 | | Number of Individuals Covered | 268 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $23,171 | | 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 $122,042 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,813 | | Insurance broker organization code? | 3 | | Insurance broker name | THOMAS J. DUDA |
|
| GEISINGER QUALITY OPTIONS, INC. (National Association of Insurance Commissioners NAIC id number: 12743 ) |
| Policy contract number | 112496 |
| Policy instance | 4 |
| Insurance contract or identification number | 112496 | | Number of Individuals Covered | 10 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-06-30 | | Total amount of commissions paid to insurance broker | USD $192 | | 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 $10,763 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $192 | | Amount paid for insurance broker fees | 16 | | Additional information about fees paid to insurance broker | BROKER FEE | | Insurance broker organization code? | 3 | | Insurance broker name | MARK S. PONDER |
|
| DENCAP DENTAL PLANS (National Association of Insurance Commissioners NAIC id number: 52025 ) |
| Policy contract number | 000450 |
| Policy instance | 2 |
| Insurance contract or identification number | 000450 | | Number of Individuals Covered | 128 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $4,959 | | 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 | 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 $49,594 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,959 | | Insurance broker organization code? | 3 | | Insurance broker name | MARK S. PONDER |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 0744323 |
| Policy instance | 5 |
| Insurance contract or identification number | 0744323 | | Number of Individuals Covered | 738 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $16,285 | | 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 $1,050,172 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $16,285 | | Amount paid for insurance broker fees | 35058 | | Additional information about fees paid to insurance broker | SERVICE FEE AGREEMENT | | Insurance broker organization code? | 3 | | Insurance broker name | MARK S. PONDER |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 303244 |
| Policy instance | 6 |
| Insurance contract or identification number | 303244 | | Number of Individuals Covered | 370 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $6,683 | | 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 | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | 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 $213,799 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,683 | | Insurance broker organization code? | 3 | | Insurance broker name | MARK S. PONDER |
|
| COMPANION LIFE (National Association of Insurance Commissioners NAIC id number: 77828 ) |
| Policy contract number | C7196 |
| Policy instance | 7 |
| Insurance contract or identification number | C7196 | | Number of Individuals Covered | 93 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $12,260 | | 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 $122,603 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $12,260 | | Insurance broker organization code? | 3 | | Insurance broker name | JOHN BRODERSEN |
|
| TOTAL HEALTH CARE USA INC (National Association of Insurance Commissioners NAIC id number: 12326 ) |
| Policy contract number | M60043 |
| Policy instance | 1 |
| Insurance contract or identification number | M60043 | | Number of Individuals Covered | 847 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $76,984 | | 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 | | Welfare Benefit Premiums Paid to Carrier | USD $2,959,718 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $76,984 | | Insurance broker organization code? | 3 | | Insurance broker name | HEALTH INSURANCE ADVISORS |
|
| DENCAP DENTAL PLANS (National Association of Insurance Commissioners NAIC id number: 52025 ) |
| Policy contract number | 000450 |
| Policy instance | 2 |
| Insurance contract or identification number | 000450 | | Number of Individuals Covered | 159 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $6,245 | | 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 | 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 $62,455 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,246 | | Insurance broker organization code? | 3 | | Insurance broker name | MARK S. PONDER |
|
| AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 ) |
| Policy contract number | V0081 |
| Policy instance | 3 |
| Insurance contract or identification number | V0081 | | Number of Individuals Covered | 303 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $68,376 | | 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 $302,774 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,859 | | Insurance broker organization code? | 3 | | Insurance broker name | THOMAS J. DUDA |
|
| GEISINGER QUALITY OPTIONS, INC. (National Association of Insurance Commissioners NAIC id number: 12743 ) |
| Policy contract number | 112496 |
| Policy instance | 4 |
| Insurance contract or identification number | 112496 | | Number of Individuals Covered | 10 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $560 | | Total amount of fees paid to insurance company | USD $16 | | 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 $39,377 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $560 | | Amount paid for insurance broker fees | 16 | | Additional information about fees paid to insurance broker | BROKER FEE | | Insurance broker organization code? | 3 | | Insurance broker name | MARK PONDER |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 0744323 |
| Policy instance | 5 |
| Insurance contract or identification number | 0744323 | | Number of Individuals Covered | 791 | | Insurance policy start date | 2012-05-01 | | Insurance policy end date | 2013-04-30 | | Total amount of commissions paid to insurance broker | USD $7,631 | | 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 $181,562 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,631 | | Insurance broker organization code? | 3 | | Insurance broker name | MARK S. PONDER |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 303244 |
| Policy instance | 6 |
| Insurance contract or identification number | 303244 | | Number of Individuals Covered | 366 | | Insurance policy start date | 2012-05-01 | | Insurance policy end date | 2013-04-30 | | Total amount of commissions paid to insurance broker | USD $5,916 | | 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 | Yes | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | 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 $226,328 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,916 | | Insurance broker organization code? | 3 | | Insurance broker name | MARK PONDER |
|
| COMPANION LIFE (National Association of Insurance Commissioners NAIC id number: 77828 ) |
| Policy contract number | C7196 |
| Policy instance | 7 |
| Insurance contract or identification number | C7196 | | Number of Individuals Covered | 87 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $13,663 | | 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 $136,626 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $13,663 | | Insurance broker organization code? | 3 | | Insurance broker name | JOHN BRODERSEN |
|
| DENCAP DENTAL PLANS (National Association of Insurance Commissioners NAIC id number: 52025 ) |
| Policy contract number | 000450 |
| Policy instance | 2 |
| Insurance contract or identification number | 000450 | | Number of Individuals Covered | 165 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $65,100 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Insurance broker organization code? | 3 | | Insurance broker name | MARK S. PONDER |
|
| AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 ) |
| Policy contract number | WV261 |
| Policy instance | 3 |
| Insurance contract or identification number | WV261 | | Number of Individuals Covered | 250 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $6,899 | | Health Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $35,728 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,782 | | Insurance broker organization code? | 3 | | Insurance broker name | MARK J. COFFEY |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AG2X |
| Policy instance | 4 |
| Insurance contract or identification number | G000AG2X | | Number of Individuals Covered | 359 | | Insurance policy start date | 2011-06-01 | | Insurance policy end date | 2012-05-01 | | Total amount of commissions paid to insurance broker | USD $18,367 | | Dental Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $308,744 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $18,367 | | Insurance broker organization code? | 3 | | Insurance broker name | A.E. MOURAD AGENCY, INC. |
|
| AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 ) |
| Policy contract number | V0081 |
| Policy instance | 5 |
| Insurance contract or identification number | V0081 | | Number of Individuals Covered | 281 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $84,383 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $248,346 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $24,815 | | Insurance broker organization code? | 3 | | Insurance broker name | JOHN BRODERSEN |
|
| GEISINGER QUALITY OPTIONS, INC. (National Association of Insurance Commissioners NAIC id number: 12743 ) |
| Policy contract number | 112496 |
| Policy instance | 6 |
| Insurance contract or identification number | 112496 | | Number of Individuals Covered | 9 | | Insurance policy start date | 2011-09-01 | | Insurance policy end date | 2012-08-31 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $28,429 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| CHARTIS (National Association of Insurance Commissioners NAIC id number: 66842 ) |
| Policy contract number | 51347 |
| Policy instance | 7 |
| Insurance contract or identification number | 51347 | | Number of Individuals Covered | 635 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-04-30 | | Total amount of commissions paid to insurance broker | USD $934 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $9,339 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $934 | | Insurance broker organization code? | 3 | | Insurance broker name | A.E. MOURAD INSURANCE AGENCY, INC. |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 0744323 |
| Policy instance | 8 |
| Insurance contract or identification number | 0744323 | | Number of Individuals Covered | 538 | | Insurance policy start date | 2012-05-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $5,878 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $124,242 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,878 | | Insurance broker organization code? | 3 | | Insurance broker name | MARK S. PONDER |
|
| COMPANION LIFE (National Association of Insurance Commissioners NAIC id number: 77828 ) |
| Policy contract number | C7196 |
| Policy instance | 9 |
| Insurance contract or identification number | C7196 | | Number of Individuals Covered | 56 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $12,911 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $129,108 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $12,911 | | Insurance broker organization code? | 3 | | Insurance broker name | JOHN BRODERSEN |
|
| TOTAL HEALTH CARE USA INC (National Association of Insurance Commissioners NAIC id number: 12326 ) |
| Policy contract number | M60043 |
| Policy instance | 1 |
| Insurance contract or identification number | M60043 | | Number of Individuals Covered | 859 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $68,160 | | Health Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $2,830,327 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $68,160 | | Insurance broker organization code? | 3 | | Insurance broker name | HEALTH INSURANCE ADVISORS |
|
