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PALACE SPORTS & ENTERTAINMENT LLC HEALTH PLAN 401k Plan overview

Plan NamePALACE SPORTS & ENTERTAINMENT LLC HEALTH PLAN
Plan identification number 501

PALACE SPORTS & ENTERTAINMENT LLC HEALTH PLAN Benefits

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

401k Sponsoring company profile

PALACE SPORTS & ENTERTAINMENT LLC has sponsored the creation of one or more 401k plans.

Company Name:PALACE SPORTS & ENTERTAINMENT LLC
Employer identification number (EIN):382670394
NAIC Classification:711300
NAIC Description: Promoters of Performing Arts, Sports, and Similar Events

Form 5500 Filing Information

Submission information for form 5500 for 401k plan PALACE SPORTS & ENTERTAINMENT LLC HEALTH PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5012018-01-01GREG CAMPBELL, CFO GREG CAMPBELL, CFO2019-07-09
5012018-01-01GREG CAMPBELL2020-10-02
5012017-01-01GREG CAMPBELL, CFO GREG CAMPBELL, CFO2018-09-11
5012017-01-01GREG CAMPBELL, CFO GREG CAMPBELL, CFO
5012017-01-01GREG CAMPBELL2020-10-02
5012016-01-01GREG CAMPBELL, CFO GREG CAMPBELL, CFO2017-06-21
5012016-01-01GREG CAMPBELL2020-10-02
5012015-01-01GREG CAMPBELL, CFO GREG CAMPBELL, CFO2016-06-02
5012015-01-01GREG CAMPBELL2020-10-02
5012014-01-01GREG CAMPBELL, CFO GREG CAMPBELL, CFO2015-07-02
5012014-01-01GREG CAMPBELL2020-10-02
5012013-01-01BOB FELLER BOB FELLER2014-07-14
5012012-01-01BOB FELLER BOB FELLER2013-07-23
5012011-01-01BOB FELLER BOB FELLER2012-10-09
5012009-01-01JOHN P OREILLY JOHN P OREILLY2010-09-30

Plan Statistics for PALACE SPORTS & ENTERTAINMENT LLC HEALTH PLAN

401k plan membership statisitcs for PALACE SPORTS & ENTERTAINMENT LLC HEALTH PLAN

Measure Date Value
2018: PALACE SPORTS & ENTERTAINMENT LLC HEALTH PLAN 2018 401k membership
Total participants, beginning-of-year2018-01-01276
Total number of active participants reported on line 7a of the Form 55002018-01-01238
Number of retired or separated participants receiving benefits2018-01-0136
Number of other retired or separated participants entitled to future benefits2018-01-010
Total of all active and inactive participants2018-01-01274
Number of employers contributing to the scheme2018-01-010
2017: PALACE SPORTS & ENTERTAINMENT LLC HEALTH PLAN 2017 401k membership
Total participants, beginning-of-year2017-01-01293
Total number of active participants reported on line 7a of the Form 55002017-01-01241
Number of retired or separated participants receiving benefits2017-01-0135
Number of other retired or separated participants entitled to future benefits2017-01-010
Total of all active and inactive participants2017-01-01276
Number of employers contributing to the scheme2017-01-010
2016: PALACE SPORTS & ENTERTAINMENT LLC HEALTH PLAN 2016 401k membership
Total participants, beginning-of-year2016-01-01228
Total number of active participants reported on line 7a of the Form 55002016-01-01293
Number of retired or separated participants receiving benefits2016-01-0130
Number of other retired or separated participants entitled to future benefits2016-01-010
Total of all active and inactive participants2016-01-01323
Number of employers contributing to the scheme2016-01-010
2015: PALACE SPORTS & ENTERTAINMENT LLC HEALTH PLAN 2015 401k membership
Total participants, beginning-of-year2015-01-01273
Total number of active participants reported on line 7a of the Form 55002015-01-01199
Number of retired or separated participants receiving benefits2015-01-0129
Number of other retired or separated participants entitled to future benefits2015-01-010
Total of all active and inactive participants2015-01-01228
Number of employers contributing to the scheme2015-01-010
2014: PALACE SPORTS & ENTERTAINMENT LLC HEALTH PLAN 2014 401k membership
Total participants, beginning-of-year2014-01-01312
Total number of active participants reported on line 7a of the Form 55002014-01-01273
Number of retired or separated participants receiving benefits2014-01-0130
Number of other retired or separated participants entitled to future benefits2014-01-010
Total of all active and inactive participants2014-01-01303
Number of employers contributing to the scheme2014-01-010
2013: PALACE SPORTS & ENTERTAINMENT LLC HEALTH PLAN 2013 401k membership
Total participants, beginning-of-year2013-01-01257
Total number of active participants reported on line 7a of the Form 55002013-01-01276
Number of retired or separated participants receiving benefits2013-01-0136
Total of all active and inactive participants2013-01-01312
2012: PALACE SPORTS & ENTERTAINMENT LLC HEALTH PLAN 2012 401k membership
Total participants, beginning-of-year2012-01-01486
Total number of active participants reported on line 7a of the Form 55002012-01-01233
Number of retired or separated participants receiving benefits2012-01-0124
Total of all active and inactive participants2012-01-01257
2011: PALACE SPORTS & ENTERTAINMENT LLC HEALTH PLAN 2011 401k membership
Total participants, beginning-of-year2011-01-01512
Total number of active participants reported on line 7a of the Form 55002011-01-01486
Total of all active and inactive participants2011-01-01486
2009: PALACE SPORTS & ENTERTAINMENT LLC HEALTH PLAN 2009 401k membership
Total participants, beginning-of-year2009-01-01704
Total number of active participants reported on line 7a of the Form 55002009-01-01597
Total of all active and inactive participants2009-01-01597

Financial Data on PALACE SPORTS & ENTERTAINMENT LLC HEALTH PLAN

Measure Date Value
2018 : PALACE SPORTS & ENTERTAINMENT LLC HEALTH PLAN 2018 401k financial data
Total income from all sources (including contributions)2018-12-31$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year2018-12-31No
Was this plan covered by a fidelity bond2018-12-31No
If this is an individual account plan, was there a blackout period2018-12-31No
Were there any nonexempt tranactions with any party-in-interest2018-12-31No
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser2018-12-31No
Value of net assets at end of year (total assets less liabilities)2018-12-31$0
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)2018-12-31No
Were any loans by the plan or fixed income obligations due to the plan in default2018-12-31No
Were any leases to which the plan was party in default or uncollectible2018-12-31No
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets2018-12-31No
Was there a failure to transmit to the plan any participant contributions2018-12-31No
Has the plan failed to provide any benefit when due under the plan2018-12-31No
Did the plan have assets held for investment2018-12-31No
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser2018-12-31No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC2018-12-31No
2017 : PALACE SPORTS & ENTERTAINMENT LLC HEALTH PLAN 2017 401k financial data
Total income from all sources (including contributions)2017-12-31$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year2017-12-31No
Was this plan covered by a fidelity bond2017-12-31No
If this is an individual account plan, was there a blackout period2017-12-31No
Were there any nonexempt tranactions with any party-in-interest2017-12-31No
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser2017-12-31No
Value of net assets at end of year (total assets less liabilities)2017-12-31$0
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)2017-12-31No
Were any loans by the plan or fixed income obligations due to the plan in default2017-12-31No
Were any leases to which the plan was party in default or uncollectible2017-12-31No
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets2017-12-31No
Was there a failure to transmit to the plan any participant contributions2017-12-31No
Has the plan failed to provide any benefit when due under the plan2017-12-31No
Did the plan have assets held for investment2017-12-31No
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser2017-12-31No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC2017-12-31No
2016 : PALACE SPORTS & ENTERTAINMENT LLC HEALTH PLAN 2016 401k financial data
Total income from all sources (including contributions)2016-12-31$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year2016-12-31No
Was this plan covered by a fidelity bond2016-12-31No
If this is an individual account plan, was there a blackout period2016-12-31No
Were there any nonexempt tranactions with any party-in-interest2016-12-31No
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser2016-12-31No
Value of net assets at end of year (total assets less liabilities)2016-12-31$0
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)2016-12-31No
Were any loans by the plan or fixed income obligations due to the plan in default2016-12-31No
Were any leases to which the plan was party in default or uncollectible2016-12-31No
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets2016-12-31No
Was there a failure to transmit to the plan any participant contributions2016-12-31No
Has the plan failed to provide any benefit when due under the plan2016-12-31No
Did the plan have assets held for investment2016-12-31No
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser2016-12-31No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC2016-12-31No
2015 : PALACE SPORTS & ENTERTAINMENT LLC HEALTH PLAN 2015 401k financial data
Total income from all sources (including contributions)2015-12-31$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year2015-12-31No
Was this plan covered by a fidelity bond2015-12-31No
If this is an individual account plan, was there a blackout period2015-12-31No
Were there any nonexempt tranactions with any party-in-interest2015-12-31No
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser2015-12-31No
Value of net assets at end of year (total assets less liabilities)2015-12-31$0
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)2015-12-31No
Were any loans by the plan or fixed income obligations due to the plan in default2015-12-31No
Were any leases to which the plan was party in default or uncollectible2015-12-31No
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets2015-12-31No
Was there a failure to transmit to the plan any participant contributions2015-12-31No
Has the plan failed to provide any benefit when due under the plan2015-12-31No
Did the plan have assets held for investment2015-12-31No
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser2015-12-31No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC2015-12-31No
2014 : PALACE SPORTS & ENTERTAINMENT LLC HEALTH PLAN 2014 401k financial data
Total income from all sources (including contributions)2014-12-31$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year2014-12-31No
Was this plan covered by a fidelity bond2014-12-31No
If this is an individual account plan, was there a blackout period2014-12-31No
Were there any nonexempt tranactions with any party-in-interest2014-12-31No
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser2014-12-31No
Value of net assets at end of year (total assets less liabilities)2014-12-31$0
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)2014-12-31No
Were any loans by the plan or fixed income obligations due to the plan in default2014-12-31No
Were any leases to which the plan was party in default or uncollectible2014-12-31No
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets2014-12-31No
Was there a failure to transmit to the plan any participant contributions2014-12-31No
Has the plan failed to provide any benefit when due under the plan2014-12-31No
Did the plan have assets held for investment2014-12-31No
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser2014-12-31No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC2014-12-31No

Form 5500 Responses for PALACE SPORTS & ENTERTAINMENT LLC HEALTH PLAN

2018: PALACE SPORTS & ENTERTAINMENT LLC HEALTH PLAN 2018 form 5500 responses
2018-01-01Type of plan entitySingle employer plan
2018-01-01Submission has been amendedYes
2018-01-01Plan funding arrangement – InsuranceYes
2018-01-01Plan funding arrangement – General assets of the sponsorYes
2018-01-01Plan benefit arrangement – InsuranceYes
2018-01-01Plan benefit arrangement – General assets of the sponsorYes
2017: PALACE SPORTS & ENTERTAINMENT LLC HEALTH PLAN 2017 form 5500 responses
2017-01-01Type of plan entitySingle employer plan
2017-01-01Submission has been amendedYes
2017-01-01Plan funding arrangement – InsuranceYes
2017-01-01Plan funding arrangement – General assets of the sponsorYes
2017-01-01Plan benefit arrangement – InsuranceYes
2017-01-01Plan benefit arrangement – General assets of the sponsorYes
2016: PALACE SPORTS & ENTERTAINMENT LLC HEALTH PLAN 2016 form 5500 responses
2016-01-01Type of plan entitySingle employer plan
2016-01-01Submission has been amendedYes
2016-01-01Plan funding arrangement – InsuranceYes
2016-01-01Plan funding arrangement – General assets of the sponsorYes
2016-01-01Plan benefit arrangement – InsuranceYes
2016-01-01Plan benefit arrangement – General assets of the sponsorYes
2015: PALACE SPORTS & ENTERTAINMENT LLC HEALTH PLAN 2015 form 5500 responses
2015-01-01Type of plan entitySingle employer plan
2015-01-01Submission has been amendedYes
2015-01-01Plan funding arrangement – InsuranceYes
2015-01-01Plan funding arrangement – General assets of the sponsorYes
2015-01-01Plan benefit arrangement – InsuranceYes
2015-01-01Plan benefit arrangement – General assets of the sponsorYes
2014: PALACE SPORTS & ENTERTAINMENT LLC HEALTH PLAN 2014 form 5500 responses
2014-01-01Type of plan entitySingle employer plan
2014-01-01Submission has been amendedYes
2014-01-01Plan funding arrangement – InsuranceYes
2014-01-01Plan funding arrangement – General assets of the sponsorYes
2014-01-01Plan benefit arrangement – InsuranceYes
2014-01-01Plan benefit arrangement – General assets of the sponsorYes
2013: PALACE SPORTS & ENTERTAINMENT LLC HEALTH PLAN 2013 form 5500 responses
2013-01-01Type of plan entityMulitple employer plan
2013-01-01Plan funding arrangement – InsuranceYes
2013-01-01Plan funding arrangement – General assets of the sponsorYes
2013-01-01Plan benefit arrangement – InsuranceYes
2013-01-01Plan benefit arrangement – General assets of the sponsorYes
2012: PALACE SPORTS & ENTERTAINMENT LLC HEALTH PLAN 2012 form 5500 responses
2012-01-01Type of plan entityMulitple employer plan
2012-01-01Plan funding arrangement – InsuranceYes
2012-01-01Plan funding arrangement – General assets of the sponsorYes
2012-01-01Plan benefit arrangement – InsuranceYes
2012-01-01Plan benefit arrangement – General assets of the sponsorYes
2011: PALACE SPORTS & ENTERTAINMENT LLC HEALTH PLAN 2011 form 5500 responses
2011-01-01Type of plan entityMulitple employer plan
2011-01-01Plan funding arrangement – InsuranceYes
2011-01-01Plan funding arrangement – General assets of the sponsorYes
2011-01-01Plan benefit arrangement – InsuranceYes
2011-01-01Plan benefit arrangement – General assets of the sponsorYes
2009: PALACE SPORTS & ENTERTAINMENT LLC HEALTH PLAN 2009 form 5500 responses
2009-01-01Type of plan entityMulitple employer plan
2009-01-01This submission is the final filingNo
2009-01-01Plan funding arrangement – InsuranceYes
2009-01-01Plan funding arrangement – General assets of the sponsorYes
2009-01-01Plan benefit arrangement – InsuranceYes
2009-01-01Plan benefit arrangement – General assets of the sponsorYes

Insurance Providers Used on plan

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberVDT960624
Policy instance 1
Insurance contract or identification numberVDT960624
Number of Individuals Covered89
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $3,351
Total amount of fees paid to insurance companyUSD $97
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $39,424
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,351
Amount paid for insurance broker fees97
Additional information about fees paid to insurance brokerSALES & SERVICE
Insurance broker organization code?7
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberFLX963379
Policy instance 2
Insurance contract or identification numberFLX963379
Number of Individuals Covered274
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $7,505
Total amount of fees paid to insurance companyUSD $195
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $88,297
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $7,505
Amount paid for insurance broker fees195
Additional information about fees paid to insurance brokerSALES & SERVICE
Insurance broker organization code?7
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberOK 965028
Policy instance 3
Insurance contract or identification numberOK 965028
Number of Individuals Covered238
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $898
Total amount of fees paid to insurance companyUSD $24
Other welfare benefits providedMEDICAL INDEMNITY AD&D
Welfare Benefit Premiums Paid to CarrierUSD $10,565
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $898
Amount paid for insurance broker fees24
Additional information about fees paid to insurance brokerSALES & SERVICE
Insurance broker organization code?7
DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 )
Policy contract number5851
Policy instance 4
Insurance contract or identification number5851
Number of Individuals Covered373
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Dental Insurance Welfare BenefitYes
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 numberGROUP 65822
Policy instance 5
Insurance contract or identification numberGROUP 65822
Number of Individuals Covered215
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $7,922
Total amount of fees paid to insurance companyUSD $59
Welfare Benefit Premiums Paid to CarrierUSD $246,469
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $7,922
Additional information about fees paid to insurance brokerCOMMISSIONS
Insurance broker organization code?3
Amount paid for insurance broker fees59
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberVDT960624
Policy instance 2
Insurance contract or identification numberVDT960624
Number of Individuals Covered274
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $11,754
Total amount of fees paid to insurance companyUSD $316
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $138,286
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $11,754
Amount paid for insurance broker fees316
Additional information about fees paid to insurance brokerSALES AND SERVICE
Insurance broker organization code?7
BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 )
Policy contract number69031
Policy instance 1
Insurance contract or identification number69031
Number of Individuals Covered215
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $7,922
Total amount of fees paid to insurance companyUSD $59
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $246,469
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $0
Amount paid for insurance broker fees59
Additional information about fees paid to insurance brokerCOMMISSIONS
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberVDT960624
Policy instance 1
Insurance contract or identification numberVDT960624
Number of Individuals Covered107
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $5,567
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $65,492
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,567
Additional information about fees paid to insurance brokerSALES & SERVICE
Insurance broker organization code?3
Insurance broker nameLUBIN SCHWARTZ & GOLDMAN
BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 )
Policy contract numberGROUP 65822
Policy instance 5
Insurance contract or identification numberGROUP 65822
Number of Individuals Covered227
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $13,250
Welfare Benefit Premiums Paid to CarrierUSD $241,765
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $8,462
Additional information about fees paid to insurance brokerCOMMISSIONS
Insurance broker organization code?3
Insurance broker nameLSG INSURANCE PARTNERS DBA
DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 )
Policy contract number5851
Policy instance 4
Insurance contract or identification number5851
Number of Individuals Covered452
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Dental Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberOK 965028
Policy instance 3
Insurance contract or identification numberOK 965028
Number of Individuals Covered241
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $1,438
Other welfare benefits providedMEDICAL INDEMNITY AD&D
Welfare Benefit Premiums Paid to CarrierUSD $16,922
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,438
Additional information about fees paid to insurance brokerSALES & SERVICE
Insurance broker organization code?3
Insurance broker nameLUBIN SCHWARTZ & GOLDMAN
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberFLX963379
Policy instance 2
Insurance contract or identification numberFLX963379
Number of Individuals Covered276
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $11,266
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $132,541
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $11,266
Additional information about fees paid to insurance brokerSALES & SERVICE
Insurance broker organization code?3
Insurance broker nameLUBIN SCHWARTZ & GOLDMAN
BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 )
Policy contract number69031
Policy instance 1
Insurance contract or identification number69031
Number of Individuals Covered227
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $13,250
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $241,765
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberVDT960624
Policy instance 2
Insurance contract or identification numberVDT960624
Number of Individuals Covered276
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $18,271
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $214,955
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 number69031
Policy instance 1
Insurance contract or identification number69031
Number of Individuals Covered270
Insurance policy start date2015-01-01
Insurance policy end date2015-12-31
Total amount of commissions paid to insurance brokerUSD $10,768
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $173,565
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $9,875
Amount paid for insurance broker fees0
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberVDT960624
Policy instance 1
Insurance contract or identification numberVDT960624
Number of Individuals Covered103
Insurance policy start date2015-01-01
Insurance policy end date2015-12-31
Total amount of commissions paid to insurance brokerUSD $2,432
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $28,606
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $296
Additional information about fees paid to insurance brokerSALES & SERVICE
Insurance broker organization code?3
Insurance broker nameLUBIN SCHWARTZ & GOLDMAN
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberFLX963379
Policy instance 2
Insurance contract or identification numberFLX963379
Number of Individuals Covered302
Insurance policy start date2015-01-01
Insurance policy end date2015-12-31
Total amount of commissions paid to insurance brokerUSD $5,689
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $72,993
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $489
Additional information about fees paid to insurance brokerSALES & SERVICE
Insurance broker organization code?3
Insurance broker nameLUBIN SCHWARTZ & GOLDMAN
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberOK 965028
Policy instance 3
Insurance contract or identification numberOK 965028
Number of Individuals Covered272
Insurance policy start date2015-01-01
Insurance policy end date2015-12-31
Total amount of commissions paid to insurance brokerUSD $1,588
Other welfare benefits providedMEDICAL INDEMNITY AD&D
Welfare Benefit Premiums Paid to CarrierUSD $10,180
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $794
Additional information about fees paid to insurance brokerSALES & SERVICE
Insurance broker organization code?3
Insurance broker nameLUBIN SCHWARTZ & GOLDMAN
DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 )
Policy contract number5851
Policy instance 4
Insurance contract or identification number5851
Number of Individuals Covered499
Insurance policy start date2015-01-01
Insurance policy end date2015-12-31
Dental Insurance Welfare BenefitYes
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 numberGROUP 65822
Policy instance 5
Insurance contract or identification numberGROUP 65822
Number of Individuals Covered270
Insurance policy start date2015-01-01
Insurance policy end date2015-12-31
Total amount of commissions paid to insurance brokerUSD $10,768
Welfare Benefit Premiums Paid to CarrierUSD $173,565
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $893
Additional information about fees paid to insurance brokerCOMMISSIONS
Insurance broker organization code?3
Insurance broker nameJAY R SCHREIBMAN
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberVDT960624
Policy instance 2
Insurance contract or identification numberVDT960624
Number of Individuals Covered302
Insurance policy start date2015-01-01
Insurance policy end date2015-12-31
Total amount of commissions paid to insurance brokerUSD $9,709
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $111,779
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $8,130
Amount paid for insurance broker fees0
Insurance broker organization code?3
UNIMERICA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 91529 )
Policy contract numberUNI-201248
Policy instance 5
Insurance contract or identification numberUNI-201248
Number of Individuals Covered303
Insurance policy start date2014-01-01
Insurance policy end date2014-12-31
Total amount of commissions paid to insurance brokerUSD $3,435
Welfare Benefit Premiums Paid to CarrierUSD $171,761
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,435
Additional information about fees paid to insurance brokerCOMMISSIONS
Insurance broker organization code?3
Insurance broker nameNGS(COURSOURCE)
DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 )
Policy contract number5851
Policy instance 4
Insurance contract or identification number5851
Number of Individuals Covered504
Insurance policy start date2014-01-01
Insurance policy end date2014-12-31
Dental Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberOK 965028
Policy instance 3
Insurance contract or identification numberOK 965028
Number of Individuals Covered273
Insurance policy start date2014-01-01
Insurance policy end date2014-12-31
Total amount of commissions paid to insurance brokerUSD $734
Total amount of fees paid to insurance companyUSD $106
Other welfare benefits providedMEDICAL INDEMNITY AD&D
Welfare Benefit Premiums Paid to CarrierUSD $8,634
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $734
Amount paid for insurance broker fees106
Additional information about fees paid to insurance brokerSALES & SERVICE
Insurance broker organization code?3
Insurance broker nameBROWN & BROWN OF DETROIT
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberFLX963379
Policy instance 2
Insurance contract or identification numberFLX963379
Number of Individuals Covered303
Insurance policy start date2014-01-01
Insurance policy end date2014-12-31
Total amount of commissions paid to insurance brokerUSD $5,922
Total amount of fees paid to insurance companyUSD $1,298
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $77,755
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,922
Amount paid for insurance broker fees1298
Additional information about fees paid to insurance brokerSALES & SERVICE
Insurance broker organization code?3
Insurance broker nameBROWN & BROWN OF DETROIT
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberVDT960624
Policy instance 1
Insurance contract or identification numberVDT960624
Number of Individuals Covered150
Insurance policy start date2014-01-01
Insurance policy end date2014-12-31
Total amount of commissions paid to insurance brokerUSD $3,791
Total amount of fees paid to insurance companyUSD $732
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $44,600
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,791
Amount paid for insurance broker fees732
Additional information about fees paid to insurance brokerSALES & SERVICE
Insurance broker organization code?3
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Insurance broker nameBROWN & BROWN OF DETROIT
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberFLX963379
Policy instance 3
Insurance contract or identification numberFLX963379
Number of Individuals Covered312
Insurance policy start date2013-01-01
Insurance policy end date2013-12-31
Total amount of commissions paid to insurance brokerUSD $7,364
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $98,080
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $7,364
Insurance broker organization code?3
Insurance broker nameBROWN & BROWN OF DETROIT, INC.
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberVDT960624
Policy instance 5
Insurance contract or identification numberVDT960624
Number of Individuals Covered194
Insurance policy start date2013-01-01
Insurance policy end date2013-12-31
Total amount of commissions paid to insurance brokerUSD $4,150
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $48,828
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,150
Insurance broker organization code?3
Insurance broker nameBROWN & BROWN OF DETROIT, INC.
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberOK965028
Policy instance 4
Insurance contract or identification numberOK965028
Number of Individuals Covered235
Insurance policy start date2013-01-01
Insurance policy end date2013-12-31
Total amount of commissions paid to insurance brokerUSD $601
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Other welfare benefits providedMEDICAL INDEMNITY, ACCIDENTAL DEATH
Welfare Benefit Premiums Paid to CarrierUSD $7,072
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $601
Insurance broker organization code?3
Insurance broker nameBROWN & BROWN OF DETROIT, INC.
UNIMERICA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 91529 )
Policy contract numberUNI-201248
Policy instance 1
Insurance contract or identification numberUNI-201248
Number of Individuals Covered248
Insurance policy start date2013-01-01
Insurance policy end date2013-12-31
Total amount of commissions paid to insurance brokerUSD $2,621
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Welfare Benefit Premiums Paid to CarrierUSD $131,033
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,621
Insurance broker organization code?3
Insurance broker nameCORESOURCE (NGS)
DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 )
Policy contract number5851
Policy instance 2
Insurance contract or identification number5851
Number of Individuals Covered459
Insurance policy start date2013-01-01
Insurance policy end date2013-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Dental Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Insurance broker organization code?3
Insurance broker nameBROWN & BROWN OF DETROIT, INC.
DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 )
Policy contract number5851
Policy instance 2
Insurance contract or identification number5851
Number of Individuals Covered491
Insurance policy start date2012-01-01
Insurance policy end date2012-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Dental Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $0
Insurance broker organization code?3
Insurance broker nameBROWN & BROWN OF DETROIT, INC.
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberVDT960624
Policy instance 5
Insurance contract or identification numberVDT960624
Number of Individuals Covered169
Insurance policy start date2012-01-01
Insurance policy end date2012-12-31
Total amount of commissions paid to insurance brokerUSD $6,444
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $66,595
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6,444
Insurance broker organization code?3
Insurance broker nameBROWN & BROWN OF DETROIT, INC.
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberOK965028
Policy instance 4
Insurance contract or identification numberOK965028
Number of Individuals Covered233
Insurance policy start date2012-01-01
Insurance policy end date2012-12-31
Total amount of commissions paid to insurance brokerUSD $603
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Other welfare benefits providedMEDICAL INDEMNITY, ACCIDENTAL DEATH
Welfare Benefit Premiums Paid to CarrierUSD $7,220
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $603
Insurance broker organization code?3
Insurance broker nameBROWN & BROWN OF DETROIT, INC.
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberFLX963379
Policy instance 3
Insurance contract or identification numberFLX963379
Number of Individuals Covered257
Insurance policy start date2012-01-01
Insurance policy end date2012-12-31
Total amount of commissions paid to insurance brokerUSD $8,411
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $114,554
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $8,411
Insurance broker organization code?3
Insurance broker nameBROWN & BROWN OF DETROIT, INC.
UNIMERICA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 91529 )
Policy contract numberUNI-201248
Policy instance 1
Insurance contract or identification numberUNI-201248
Number of Individuals Covered243
Insurance policy start date2012-01-01
Insurance policy end date2012-12-31
Total amount of commissions paid to insurance brokerUSD $2,315
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Welfare Benefit Premiums Paid to CarrierUSD $115,748
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,315
Insurance broker organization code?3
Insurance broker nameCORESOURCE (ERISCO)
DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 )
Policy contract number5851
Policy instance 2
Insurance contract or identification number5851
Number of Individuals Covered486
Insurance policy start date2011-01-01
Insurance policy end date2011-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Dental Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberFLX963379
Policy instance 3
Insurance contract or identification numberFLX963379
Number of Individuals Covered221
Insurance policy start date2011-01-01
Insurance policy end date2011-12-31
Total amount of commissions paid to insurance brokerUSD $5,177
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $60,907
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberVDT960624
Policy instance 5
Insurance contract or identification numberVDT960624
Number of Individuals Covered167
Insurance policy start date2011-01-01
Insurance policy end date2011-12-31
Total amount of commissions paid to insurance brokerUSD $3,869
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $45,522
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
UNIMERICA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 91529 )
Policy contract numberUNI-201248
Policy instance 1
Insurance contract or identification numberUNI-201248
Number of Individuals Covered224
Insurance policy start date2011-01-01
Insurance policy end date2011-12-31
Total amount of commissions paid to insurance brokerUSD $2,055
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Welfare Benefit Premiums Paid to CarrierUSD $102,728
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberOK965028
Policy instance 4
Insurance contract or identification numberOK965028
Number of Individuals Covered221
Insurance policy start date2011-01-01
Insurance policy end date2011-12-31
Total amount of commissions paid to insurance brokerUSD $477
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Other welfare benefits providedMEDICAL INDEMNITY, ACCIDENTAL DEATH
Welfare Benefit Premiums Paid to CarrierUSD $5,618
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberVDT960624
Policy instance 5
Insurance contract or identification numberVDT960624
Insurance policy start date2010-01-01
Insurance policy end date2010-12-31
Total amount of commissions paid to insurance brokerUSD $4,418
Total amount of fees paid to insurance companyUSD $1,494
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $54,115
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,418
Amount paid for insurance broker fees1494
Additional information about fees paid to insurance brokerSALES & SERVICE
Insurance broker organization code?3
Insurance broker nameBROWN & BROWN OF DETROIT, INC.
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberFLX963379
Policy instance 3
Insurance contract or identification numberFLX963379
Insurance policy start date2010-01-01
Insurance policy end date2010-12-31
Total amount of commissions paid to insurance brokerUSD $6,012
Total amount of fees paid to insurance companyUSD $1,537
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $50,385
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6,012
Amount paid for insurance broker fees1537
Additional information about fees paid to insurance brokerSALES & SERVICE
Insurance broker organization code?3
Insurance broker nameBROWN & BROWN OF DETROIT, INC.
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberOK965028
Policy instance 4
Insurance contract or identification numberOK965028
Insurance policy start date2010-01-01
Insurance policy end date2010-12-31
Total amount of commissions paid to insurance brokerUSD $351
Total amount of fees paid to insurance companyUSD $234
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Other welfare benefits providedMEDICAL INDEMNITY, ACCIDENTAL DEATH
Welfare Benefit Premiums Paid to CarrierUSD $6,532
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $351
Amount paid for insurance broker fees234
Additional information about fees paid to insurance brokerSALES & SERVICE
Insurance broker organization code?3
Insurance broker nameBROWN & BROWN OF DETROIT, INC.
DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 )
Policy contract number5851
Policy instance 2
Insurance contract or identification number5851
Number of Individuals Covered512
Insurance policy start date2010-01-01
Insurance policy end date2010-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $14,226
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Dental Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Amount paid for insurance broker fees14226
Additional information about fees paid to insurance brokerADMIN SERVICE OR OTHER FEE
Insurance broker organization code?3
Insurance broker nameRICHARD MONAHAN
SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )
Policy contract number096121
Policy instance 1
Insurance contract or identification number096121
Number of Individuals Covered253
Insurance policy start date2010-01-01
Insurance policy end date2010-12-31
Total amount of commissions paid to insurance brokerUSD $2,052
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Welfare Benefit Premiums Paid to CarrierUSD $102,136
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,052
Additional information about fees paid to insurance brokerADMIN SERVICE OR OTHER FEE
Insurance broker organization code?3
Insurance broker nameBROWN & BROWN OF DETROIT, INC.

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