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GARDNER WHITE FURNITURE CO.,INC WELFARE PLAN 401k Plan overview

Plan NameGARDNER WHITE FURNITURE CO.,INC WELFARE PLAN
Plan identification number 501

GARDNER WHITE FURNITURE CO.,INC WELFARE 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)
  • Other welfare benefit cover

401k Sponsoring company profile

GARDNER WHITE FURNITURE CO., INC has sponsored the creation of one or more 401k plans.

Company Name:GARDNER WHITE FURNITURE CO., INC
Employer identification number (EIN):382754153
NAIC Classification:442110
NAIC Description:Furniture Stores

Form 5500 Filing Information

Submission information for form 5500 for 401k plan GARDNER WHITE FURNITURE CO.,INC WELFARE PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5012022-04-01MATT DOLMAGE, CFO2022-12-17
5012021-04-01MATT DOLMAGE, CFO2022-12-13
5012020-04-01MATT DOLMAGE, CFO2021-11-08
5012019-04-01MATT DOLMAGE, CFO2021-01-05
5012018-04-01BARBARA TRONSTEIN2020-01-12
5012017-04-01
5012016-04-01BARBARA TRONSTEIN
5012015-04-01BARBARA TRONSTEIN
5012014-04-01BARBARA TRONSTEIN
5012014-01-01BARBARA TRONSTEIN
5012013-01-01BARBARA TRONSTEIN BARBARA TRONSTEIN2014-11-10
5012012-01-01BARBARA TRONSTEIN BARBARA TRONSTEIN2013-10-24
5012011-01-01BARBARA TRONSTEIN BARBARA TRONSTEIN2013-01-30

Plan Statistics for GARDNER WHITE FURNITURE CO.,INC WELFARE PLAN

401k plan membership statisitcs for GARDNER WHITE FURNITURE CO.,INC WELFARE PLAN

Measure Date Value
2022: GARDNER WHITE FURNITURE CO.,INC WELFARE PLAN 2022 401k membership
Total participants, beginning-of-year2022-04-01827
Total number of active participants reported on line 7a of the Form 55002022-04-01776
Number of retired or separated participants receiving benefits2022-04-012
Number of other retired or separated participants entitled to future benefits2022-04-010
Total of all active and inactive participants2022-04-01778
2021: GARDNER WHITE FURNITURE CO.,INC WELFARE PLAN 2021 401k membership
Total participants, beginning-of-year2021-04-01786
Total number of active participants reported on line 7a of the Form 55002021-04-01829
Number of retired or separated participants receiving benefits2021-04-012
Number of other retired or separated participants entitled to future benefits2021-04-010
Total of all active and inactive participants2021-04-01831
2020: GARDNER WHITE FURNITURE CO.,INC WELFARE PLAN 2020 401k membership
Total participants, beginning-of-year2020-04-01413
Total number of active participants reported on line 7a of the Form 55002020-04-01768
Number of other retired or separated participants entitled to future benefits2020-04-010
Total of all active and inactive participants2020-04-01768
2019: GARDNER WHITE FURNITURE CO.,INC WELFARE PLAN 2019 401k membership
Total participants, beginning-of-year2019-04-01338
Total number of active participants reported on line 7a of the Form 55002019-04-01332
Number of retired or separated participants receiving benefits2019-04-010
Number of other retired or separated participants entitled to future benefits2019-04-010
Total of all active and inactive participants2019-04-01332
2018: GARDNER WHITE FURNITURE CO.,INC WELFARE PLAN 2018 401k membership
Total participants, beginning-of-year2018-04-01517
Total number of active participants reported on line 7a of the Form 55002018-04-01341
Number of retired or separated participants receiving benefits2018-04-0182
Number of other retired or separated participants entitled to future benefits2018-04-010
Total of all active and inactive participants2018-04-01423
2017: GARDNER WHITE FURNITURE CO.,INC WELFARE PLAN 2017 401k membership
Total participants, beginning-of-year2017-04-01483
Total number of active participants reported on line 7a of the Form 55002017-04-01261
Number of retired or separated participants receiving benefits2017-04-010
Number of other retired or separated participants entitled to future benefits2017-04-010
Total of all active and inactive participants2017-04-01261
2016: GARDNER WHITE FURNITURE CO.,INC WELFARE PLAN 2016 401k membership
Total participants, beginning-of-year2016-04-01483
Total number of active participants reported on line 7a of the Form 55002016-04-01446
Number of retired or separated participants receiving benefits2016-04-010
Number of other retired or separated participants entitled to future benefits2016-04-010
Total of all active and inactive participants2016-04-01446
2015: GARDNER WHITE FURNITURE CO.,INC WELFARE PLAN 2015 401k membership
Total participants, beginning-of-year2015-04-01435
Total number of active participants reported on line 7a of the Form 55002015-04-01359
Number of retired or separated participants receiving benefits2015-04-010
Number of other retired or separated participants entitled to future benefits2015-04-010
Total of all active and inactive participants2015-04-01359
2014: GARDNER WHITE FURNITURE CO.,INC WELFARE PLAN 2014 401k membership
Total participants, beginning-of-year2014-04-01368
Total number of active participants reported on line 7a of the Form 55002014-04-01319
Number of retired or separated participants receiving benefits2014-04-010
Number of other retired or separated participants entitled to future benefits2014-04-010
Total of all active and inactive participants2014-04-01319
Total participants, beginning-of-year2014-01-01341
Total number of active participants reported on line 7a of the Form 55002014-01-01252
Number of retired or separated participants receiving benefits2014-01-010
Number of other retired or separated participants entitled to future benefits2014-01-010
Total of all active and inactive participants2014-01-01252
2013: GARDNER WHITE FURNITURE CO.,INC WELFARE PLAN 2013 401k membership
Total participants, beginning-of-year2013-01-01460
Total number of active participants reported on line 7a of the Form 55002013-01-01379
Number of retired or separated participants receiving benefits2013-01-010
Number of other retired or separated participants entitled to future benefits2013-01-010
Total of all active and inactive participants2013-01-01379
2012: GARDNER WHITE FURNITURE CO.,INC WELFARE PLAN 2012 401k membership
Total participants, beginning-of-year2012-01-01257
Total number of active participants reported on line 7a of the Form 55002012-01-01460
Number of retired or separated participants receiving benefits2012-01-010
Number of other retired or separated participants entitled to future benefits2012-01-010
Total of all active and inactive participants2012-01-01460
2011: GARDNER WHITE FURNITURE CO.,INC WELFARE PLAN 2011 401k membership
Total participants, beginning-of-year2011-01-01266
Total number of active participants reported on line 7a of the Form 55002011-01-01257
Number of retired or separated participants receiving benefits2011-01-010
Number of other retired or separated participants entitled to future benefits2011-01-010
Total of all active and inactive participants2011-01-01257

Form 5500 Responses for GARDNER WHITE FURNITURE CO.,INC WELFARE PLAN

2022: GARDNER WHITE FURNITURE CO.,INC WELFARE PLAN 2022 form 5500 responses
2022-04-01Type of plan entitySingle employer plan
2022-04-01This return/report is a short plan year return/report (less than 12 months)Yes
2022-04-01Plan funding arrangement – General assets of the sponsorYes
2022-04-01Plan benefit arrangement – InsuranceYes
2022-04-01Plan benefit arrangement – General assets of the sponsorYes
2021: GARDNER WHITE FURNITURE CO.,INC WELFARE PLAN 2021 form 5500 responses
2021-04-01Type of plan entitySingle employer plan
2021-04-01Plan funding arrangement – General assets of the sponsorYes
2021-04-01Plan benefit arrangement – InsuranceYes
2021-04-01Plan benefit arrangement – General assets of the sponsorYes
2020: GARDNER WHITE FURNITURE CO.,INC WELFARE PLAN 2020 form 5500 responses
2020-04-01Type of plan entitySingle employer plan
2020-04-01Plan funding arrangement – General assets of the sponsorYes
2020-04-01Plan benefit arrangement – InsuranceYes
2020-04-01Plan benefit arrangement – General assets of the sponsorYes
2019: GARDNER WHITE FURNITURE CO.,INC WELFARE PLAN 2019 form 5500 responses
2019-04-01Type of plan entitySingle employer plan
2019-04-01Plan funding arrangement – General assets of the sponsorYes
2019-04-01Plan benefit arrangement – InsuranceYes
2019-04-01Plan benefit arrangement – General assets of the sponsorYes
2018: GARDNER WHITE FURNITURE CO.,INC WELFARE PLAN 2018 form 5500 responses
2018-04-01Type of plan entitySingle employer plan
2018-04-01Plan funding arrangement – General assets of the sponsorYes
2018-04-01Plan benefit arrangement – InsuranceYes
2018-04-01Plan benefit arrangement – General assets of the sponsorYes
2017: GARDNER WHITE FURNITURE CO.,INC WELFARE PLAN 2017 form 5500 responses
2017-04-01Type of plan entitySingle employer plan
2017-04-01Plan funding arrangement – General assets of the sponsorYes
2017-04-01Plan benefit arrangement – InsuranceYes
2017-04-01Plan benefit arrangement – General assets of the sponsorYes
2016: GARDNER WHITE FURNITURE CO.,INC WELFARE PLAN 2016 form 5500 responses
2016-04-01Type of plan entitySingle employer plan
2016-04-01Plan funding arrangement – General assets of the sponsorYes
2016-04-01Plan benefit arrangement – InsuranceYes
2016-04-01Plan benefit arrangement – General assets of the sponsorYes
2015: GARDNER WHITE FURNITURE CO.,INC WELFARE PLAN 2015 form 5500 responses
2015-04-01Type of plan entitySingle employer plan
2015-04-01Plan funding arrangement – General assets of the sponsorYes
2015-04-01Plan benefit arrangement – InsuranceYes
2015-04-01Plan benefit arrangement – General assets of the sponsorYes
2014: GARDNER WHITE FURNITURE CO.,INC WELFARE PLAN 2014 form 5500 responses
2014-04-01Type of plan entitySingle employer plan
2014-04-01Plan funding arrangement – General assets of the sponsorYes
2014-04-01Plan benefit arrangement – InsuranceYes
2014-04-01Plan benefit arrangement – General assets of the sponsorYes
2014-01-01Type of plan entitySingle employer plan
2014-01-01This return/report is a short plan year return/report (less than 12 months)Yes
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: GARDNER WHITE FURNITURE CO.,INC WELFARE PLAN 2013 form 5500 responses
2013-01-01Type of plan entitySingle employer plan
2013-01-01Plan funding arrangement – InsuranceYes
2013-01-01Plan benefit arrangement – InsuranceYes
2012: GARDNER WHITE FURNITURE CO.,INC WELFARE PLAN 2012 form 5500 responses
2012-01-01Type of plan entitySingle employer plan
2012-01-01Plan funding arrangement – InsuranceYes
2012-01-01Plan benefit arrangement – InsuranceYes
2011: GARDNER WHITE FURNITURE CO.,INC WELFARE PLAN 2011 form 5500 responses
2011-01-01Type of plan entitySingle employer plan
2011-01-01First time form 5500 has been submittedYes
2011-01-01Plan funding arrangement – InsuranceYes
2011-01-01Plan benefit arrangement – InsuranceYes

Insurance Providers Used on plan

DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 )
Policy contract number10567
Policy instance 12
Insurance contract or identification number10567
Number of Individuals Covered250
Insurance policy start date2022-08-01
Insurance policy end date2023-07-31
Total amount of commissions paid to insurance brokerUSD $2,157
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,157
Insurance broker organization code?3
BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 )
Policy contract number255278
Policy instance 1
Insurance contract or identification number255278
Number of Individuals Covered213
Insurance policy start date2022-08-01
Insurance policy end date2023-07-31
Total amount of commissions paid to insurance brokerUSD $58,423
Total amount of fees paid to insurance companyUSD $1,514
Health Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $21,123
Insurance broker organization code?3
Amount paid for insurance broker fees1514
BLUE CARE NETWORK OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 95610 )
Policy contract number255278
Policy instance 2
Insurance contract or identification number255278
Number of Individuals Covered834
Insurance policy start date2022-08-01
Insurance policy end date2023-07-31
Total amount of commissions paid to insurance brokerUSD $156,719
Total amount of fees paid to insurance companyUSD $5,785
Health Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $55,032
Insurance broker organization code?3
Amount paid for insurance broker fees5785
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract numberR0737528
Policy instance 3
Insurance contract or identification numberR0737528
Number of Individuals Covered644
Insurance policy start date2022-08-01
Insurance policy end date2023-07-31
Total amount of commissions paid to insurance brokerUSD $35,489
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedGRPACCVOEN & GRPHSPVOEN
Welfare Benefit Premiums Paid to CarrierUSD $174,248
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $32,783
Insurance broker organization code?3
PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )
Policy contract number0011972648
Policy instance 4
Insurance contract or identification number0011972648
Number of Individuals Covered337
Insurance policy start date2022-08-01
Insurance policy end date2023-07-31
Total amount of commissions paid to insurance brokerUSD $29,661
Total amount of fees paid to insurance companyUSD $0
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $105,548
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $26,395
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberG000BVQ4
Policy instance 5
Insurance contract or identification numberG000BVQ4
Number of Individuals Covered801
Insurance policy start date2022-08-01
Insurance policy end date2023-07-31
Total amount of commissions paid to insurance brokerUSD $993
Total amount of fees paid to insurance companyUSD $389
Life Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $9,931
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $993
Insurance broker organization code?3
Amount paid for insurance broker fees389
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberG000BVQ4
Policy instance 6
Insurance contract or identification numberG000BVQ4
Number of Individuals Covered297
Insurance policy start date2022-08-01
Insurance policy end date2023-07-31
Total amount of commissions paid to insurance brokerUSD $6,595
Total amount of fees paid to insurance companyUSD $3,371
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $187,539
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6,595
Insurance broker organization code?3
Amount paid for insurance broker fees3371
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberG000BVQ4
Policy instance 7
Insurance contract or identification numberG000BVQ4
Number of Individuals Covered36
Insurance policy start date2022-08-01
Insurance policy end date2023-07-31
Total amount of commissions paid to insurance brokerUSD $1,454
Total amount of fees paid to insurance companyUSD $388
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $14,543
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,454
Insurance broker organization code?3
Amount paid for insurance broker fees388
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberG000BVQ4
Policy instance 8
Insurance contract or identification numberG000BVQ4
Number of Individuals Covered188
Insurance policy start date2022-08-01
Insurance policy end date2023-07-31
Total amount of commissions paid to insurance brokerUSD $5,328
Total amount of fees paid to insurance companyUSD $2,140
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $103,751
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,328
Insurance broker organization code?3
Amount paid for insurance broker fees2140
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberG000BVQ4
Policy instance 9
Insurance contract or identification numberG000BVQ4
Number of Individuals Covered206
Insurance policy start date2022-08-01
Insurance policy end date2023-07-31
Total amount of commissions paid to insurance brokerUSD $8,493
Total amount of fees paid to insurance companyUSD $2,780
Life Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $81,876
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $8,493
Insurance broker organization code?3
Amount paid for insurance broker fees2780
NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 )
Policy contract number3242
Policy instance 10
Insurance contract or identification number3242
Number of Individuals Covered936
Insurance policy start date2022-08-01
Insurance policy end date2023-07-31
Total amount of commissions paid to insurance brokerUSD $6,754
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $67,535
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6,754
Insurance broker organization code?3
DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 )
Policy contract number10567
Policy instance 11
Insurance contract or identification number10567
Number of Individuals Covered865
Insurance policy start date2022-08-01
Insurance policy end date2023-07-31
Total amount of commissions paid to insurance brokerUSD $17,273
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $17,273
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberG000BVQ4
Policy instance 9
Insurance contract or identification numberG000BVQ4
Number of Individuals Covered191
Insurance policy start date2022-04-01
Insurance policy end date2022-07-31
Total amount of commissions paid to insurance brokerUSD $3,748
Total amount of fees paid to insurance companyUSD $0
Life Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $24,985
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,748
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberG000BVQ4
Policy instance 7
Insurance contract or identification numberG000BVQ4
Number of Individuals Covered38
Insurance policy start date2022-04-01
Insurance policy end date2022-07-31
Total amount of commissions paid to insurance brokerUSD $375
Total amount of fees paid to insurance companyUSD $0
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $3,754
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $375
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberG000BVQ4
Policy instance 6
Insurance contract or identification numberG000BVQ4
Number of Individuals Covered241
Insurance policy start date2022-04-01
Insurance policy end date2022-07-31
Total amount of commissions paid to insurance brokerUSD $3,657
Total amount of fees paid to insurance companyUSD $0
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $43,145
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,657
Insurance broker organization code?3
PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )
Policy contract number0011972648
Policy instance 4
Insurance contract or identification number0011972648
Number of Individuals Covered306
Insurance policy start date2022-04-01
Insurance policy end date2022-07-31
Total amount of commissions paid to insurance brokerUSD $10,924
Total amount of fees paid to insurance companyUSD $0
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $23,530
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $9,697
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberG000BVQ4
Policy instance 5
Insurance contract or identification numberG000BVQ4
Number of Individuals Covered814
Insurance policy start date2022-04-01
Insurance policy end date2022-07-31
Total amount of commissions paid to insurance brokerUSD $337
Total amount of fees paid to insurance companyUSD $0
Life Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $3,365
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $337
Insurance broker organization code?3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract numberR0737528
Policy instance 3
Insurance contract or identification numberR0737528
Number of Individuals Covered464
Insurance policy start date2022-04-01
Insurance policy end date2022-07-31
Total amount of commissions paid to insurance brokerUSD $8,973
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedGRPACCVOEN & GRPHSPVOEN
Welfare Benefit Premiums Paid to CarrierUSD $33,550
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $8,136
Insurance broker organization code?3
BLUE CARE NETWORK OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 95610 )
Policy contract number255278
Policy instance 2
Insurance contract or identification number255278
Number of Individuals Covered812
Insurance policy start date2022-04-01
Insurance policy end date2022-07-31
Total amount of commissions paid to insurance brokerUSD $54,082
Total amount of fees paid to insurance companyUSD $2,480
Health Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $54,082
Insurance broker organization code?3
Amount paid for insurance broker fees1442
BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 )
Policy contract number255278
Policy instance 1
Insurance contract or identification number255278
Number of Individuals Covered181
Insurance policy start date2022-04-01
Insurance policy end date2022-07-31
Total amount of commissions paid to insurance brokerUSD $15,881
Total amount of fees paid to insurance companyUSD $428
Health Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $15,881
Insurance broker organization code?3
Amount paid for insurance broker fees272
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberG000BVQ4
Policy instance 8
Insurance contract or identification numberG000BVQ4
Number of Individuals Covered170
Insurance policy start date2022-04-01
Insurance policy end date2022-07-31
Total amount of commissions paid to insurance brokerUSD $3,388
Total amount of fees paid to insurance companyUSD $0
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $27,769
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,388
Insurance broker organization code?3
BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 )
Policy contract number255278
Policy instance 1
Insurance contract or identification number255278
Number of Individuals Covered136
Insurance policy start date2021-04-01
Insurance policy end date2022-03-31
Total amount of commissions paid to insurance brokerUSD $47,642
Total amount of fees paid to insurance companyUSD $1,285
Health Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $47,642
Insurance broker organization code?3
Amount paid for insurance broker fees817
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberG000BVQ4
Policy instance 7
Insurance contract or identification numberG000BVQ4
Number of Individuals Covered185
Insurance policy start date2021-04-01
Insurance policy end date2022-03-31
Total amount of commissions paid to insurance brokerUSD $7,547
Total amount of fees paid to insurance companyUSD $3,062
Life Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $70,783
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $7,547
Insurance broker organization code?3
Amount paid for insurance broker fees3062
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberG000BVQ4
Policy instance 6
Insurance contract or identification numberG000BVQ4
Number of Individuals Covered34
Insurance policy start date2021-04-01
Insurance policy end date2022-03-31
Total amount of commissions paid to insurance brokerUSD $984
Total amount of fees paid to insurance companyUSD $451
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $9,839
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $984
Insurance broker organization code?3
Amount paid for insurance broker fees451
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberG000BVQ4
Policy instance 5
Insurance contract or identification numberG000BVQ4
Number of Individuals Covered802
Insurance policy start date2021-04-01
Insurance policy end date2022-03-31
Total amount of commissions paid to insurance brokerUSD $981
Total amount of fees paid to insurance companyUSD $451
Life Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $9,807
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $981
Insurance broker organization code?3
Amount paid for insurance broker fees451
PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )
Policy contract number0011972648
Policy instance 4
Insurance contract or identification number0011972648
Number of Individuals Covered399
Insurance policy start date2021-04-01
Insurance policy end date2022-03-31
Total amount of commissions paid to insurance brokerUSD $64,798
Total amount of fees paid to insurance companyUSD $0
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $112,409
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $57,882
Insurance broker organization code?3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract numberR0737528
Policy instance 3
Insurance contract or identification numberR0737528
Number of Individuals Covered631
Insurance policy start date2021-04-01
Insurance policy end date2022-03-31
Total amount of commissions paid to insurance brokerUSD $52,532
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedGRPACCVOEN & GRPHSPVOEN
Welfare Benefit Premiums Paid to CarrierUSD $160,957
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $47,115
Insurance broker organization code?3
BLUE CARE NETWORK OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 95610 )
Policy contract number255278
Policy instance 2
Insurance contract or identification number255278
Number of Individuals Covered609
Insurance policy start date2021-04-01
Insurance policy end date2022-03-31
Total amount of commissions paid to insurance brokerUSD $162,246
Total amount of fees paid to insurance companyUSD $7,439
Health Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $162,246
Insurance broker organization code?3
Amount paid for insurance broker fees4325
PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )
Policy contract number0011972648
Policy instance 5
Insurance contract or identification number0011972648
Number of Individuals Covered200
Insurance policy start date2020-04-01
Insurance policy end date2021-03-31
Total amount of commissions paid to insurance brokerUSD $16,793
Total amount of fees paid to insurance companyUSD $0
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $45,080
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $12,375
Insurance broker organization code?3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract numberR0737528
Policy instance 4
Insurance contract or identification numberR0737528
Number of Individuals Covered355
Insurance policy start date2020-04-01
Insurance policy end date2021-03-31
Total amount of commissions paid to insurance brokerUSD $22,885
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedGRPACCVOEN & GRPHSPVOEN
Welfare Benefit Premiums Paid to CarrierUSD $82,925
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $15,073
Insurance broker organization code?3
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number00402757
Policy instance 3
Insurance contract or identification number00402757
Number of Individuals Covered768
Insurance policy start date2020-04-01
Insurance policy end date2021-03-31
Total amount of commissions paid to insurance brokerUSD $30,557
Total amount of fees paid to insurance companyUSD $14,446
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $331,133
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $30,557
Amount paid for insurance broker fees14446
Insurance broker organization code?3
BLUE CARE NETWORK OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 95610 )
Policy contract number255278
Policy instance 2
Insurance contract or identification number255278
Number of Individuals Covered674
Insurance policy start date2020-04-01
Insurance policy end date2021-03-31
Total amount of commissions paid to insurance brokerUSD $104,532
Total amount of fees paid to insurance companyUSD $1,487
Health Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $104,532
Insurance broker organization code?3
Amount paid for insurance broker fees1487
BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 )
Policy contract number255278
Policy instance 1
Insurance contract or identification number255278
Number of Individuals Covered97
Insurance policy start date2020-04-01
Insurance policy end date2021-03-31
Total amount of commissions paid to insurance brokerUSD $26,659
Total amount of fees paid to insurance companyUSD $68
Health Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $26,659
Insurance broker organization code?3
Amount paid for insurance broker fees68
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract numberR0737528
Policy instance 4
Insurance contract or identification numberR0737528
Number of Individuals Covered267
Insurance policy start date2019-04-01
Insurance policy end date2020-03-31
Total amount of commissions paid to insurance brokerUSD $34,644
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedGRP HSP VOL 12 & GRP ACC VOL 11
Welfare Benefit Premiums Paid to CarrierUSD $67,546
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $25,199
Insurance broker organization code?3
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number00402757
Policy instance 3
Insurance contract or identification number00402757
Number of Individuals Covered407
Insurance policy start date2019-04-01
Insurance policy end date2020-03-31
Total amount of commissions paid to insurance brokerUSD $27,914
Total amount of fees paid to insurance companyUSD $16,415
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $302,680
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $27,914
Amount paid for insurance broker fees16415
Insurance broker organization code?3
BLUE CARE NETWORK OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 95610 )
Policy contract number255278
Policy instance 2
Insurance contract or identification number255278
Number of Individuals Covered449
Insurance policy start date2019-04-01
Insurance policy end date2020-03-31
Total amount of commissions paid to insurance brokerUSD $86,623
Total amount of fees paid to insurance companyUSD $3,063
Health Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $86,623
Insurance broker organization code?3
Amount paid for insurance broker fees3063
BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 )
Policy contract number255278
Policy instance 1
Insurance contract or identification number255278
Number of Individuals Covered23
Insurance policy start date2019-04-01
Insurance policy end date2020-03-31
Total amount of commissions paid to insurance brokerUSD $6,911
Total amount of fees paid to insurance companyUSD $130
Health Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6,911
Insurance broker organization code?3
Amount paid for insurance broker fees130
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number00402757
Policy instance 3
Insurance contract or identification number00402757
Number of Individuals Covered415
Insurance policy start date2018-04-01
Insurance policy end date2019-03-31
Total amount of commissions paid to insurance brokerUSD $29,690
Total amount of fees paid to insurance companyUSD $15,110
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $312,376
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $29,690
Amount paid for insurance broker fees15110
Insurance broker organization code?3
BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 )
Policy contract number255278
Policy instance 1
Insurance contract or identification number255278
Number of Individuals Covered21
Insurance policy start date2018-04-01
Insurance policy end date2019-03-31
Total amount of commissions paid to insurance brokerUSD $7,880
Total amount of fees paid to insurance companyUSD $43
Health 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 fees43
Insurance broker organization code?3
Commission paid to Insurance BrokerUSD $7,880
BLUE CARE NETWORK OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 95610 )
Policy contract number255278
Policy instance 2
Insurance contract or identification number255278
Number of Individuals Covered489
Insurance policy start date2018-04-01
Insurance policy end date2019-03-31
Total amount of commissions paid to insurance brokerUSD $95,182
Total amount of fees paid to insurance companyUSD $1,535
Health Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $95,182
Insurance broker organization code?3
Amount paid for insurance broker fees1535
BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 )
Policy contract number255278
Policy instance 1
Insurance contract or identification number255278
Number of Individuals Covered14
Insurance policy start date2017-04-01
Insurance policy end date2018-03-31
Total amount of commissions paid to insurance brokerUSD $7,169
Total amount of fees paid to insurance companyUSD $120
Health Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6,728
Insurance broker organization code?3
Amount paid for insurance broker fees120
Insurance broker nameLSG INSURANCE PARTNERS
BLUE CARE NETWORK OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 95610 )
Policy contract number255278
Policy instance 2
Insurance contract or identification number255278
Number of Individuals Covered498
Insurance policy start date2017-04-01
Insurance policy end date2018-03-31
Total amount of commissions paid to insurance brokerUSD $101,650
Total amount of fees paid to insurance companyUSD $4,457
Health Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $101,650
Insurance broker organization code?3
Amount paid for insurance broker fees4457
Insurance broker nameLSG INSURANCE PARTNERS
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number00402757
Policy instance 3
Insurance contract or identification number00402757
Number of Individuals Covered432
Insurance policy start date2017-04-01
Insurance policy end date2018-03-31
Total amount of commissions paid to insurance brokerUSD $24,268
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $261,419
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $24,268
Insurance broker organization code?3
Insurance broker nameLSG INSURANCE PARTNERS
BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 )
Policy contract number62045-760
Policy instance 1
Insurance contract or identification number62045-760
Number of Individuals Covered4
Insurance policy start date2015-04-01
Insurance policy end date2016-03-31
Total amount of commissions paid to insurance brokerUSD $669
Welfare Benefit Premiums Paid to CarrierUSD $34,371
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $669
Insurance broker organization code?3
Insurance broker nameJAY R SCHREIBMAN
BLUE CARE NETWORK OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 95610 )
Policy contract number00255278/0001
Policy instance 2
Insurance contract or identification number00255278/0001
Number of Individuals Covered492
Insurance policy start date2015-04-01
Insurance policy end date2016-03-31
Total amount of commissions paid to insurance brokerUSD $67,891
Welfare Benefit Premiums Paid to CarrierUSD $1,527,920
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $67,891
Insurance broker organization code?3
Insurance broker nameLUBIN SCHWARTZ & GOLDMAN INC
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number07294
Policy instance 4
Insurance contract or identification number07294
Number of Individuals Covered64
Insurance policy start date2015-04-01
Insurance policy end date2016-03-31
Total amount of commissions paid to insurance brokerUSD $2,163
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $14,421
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,163
Additional information about fees paid to insurance brokerSALES & SERVICE COMPENSATION
Insurance broker organization code?3
Insurance broker nameLUBIN SCHWARTZ & GOLDMAN INC
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number00402757
Policy instance 3
Insurance contract or identification number00402757
Number of Individuals Covered363
Insurance policy start date2015-04-01
Insurance policy end date2016-03-31
Total amount of commissions paid to insurance brokerUSD $23,244
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $254,416
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $23,244
Insurance broker organization code?3
Insurance broker nameLUBIN SCHWARTZ & GOLDMAN INC
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number07294
Policy instance 4
Insurance contract or identification number07294
Number of Individuals Covered66
Insurance policy start date2014-04-01
Insurance policy end date2015-03-31
Total amount of commissions paid to insurance brokerUSD $2,230
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $14,865
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,230
Additional information about fees paid to insurance brokerSALES & SERVICE COMPENSATION
Insurance broker organization code?3
Insurance broker nameLUBIN SCHWARTZ & GOLDMAN INC
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number00402757
Policy instance 3
Insurance contract or identification number00402757
Number of Individuals Covered367
Insurance policy start date2014-04-01
Insurance policy end date2015-03-31
Total amount of commissions paid to insurance brokerUSD $19,986
Total amount of fees paid to insurance companyUSD $9,461
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $221,532
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $19,986
Amount paid for insurance broker fees9461
Insurance broker organization code?3
Insurance broker nameLUBIN SCHWARTZ & GOLDMAN INC
BLUE CARE NETWORK OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 95610 )
Policy contract number00255278/0001
Policy instance 2
Insurance contract or identification number00255278/0001
Number of Individuals Covered497
Insurance policy start date2014-04-01
Insurance policy end date2015-03-31
Total amount of commissions paid to insurance brokerUSD $69,146
Welfare Benefit Premiums Paid to CarrierUSD $1,435,128
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $69,146
Insurance broker organization code?3
Insurance broker nameLUBIN SCHWARTZ & GOLDMAN INC
BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 )
Policy contract number62045-760
Policy instance 1
Insurance contract or identification number62045-760
Number of Individuals Covered3
Insurance policy start date2014-04-01
Insurance policy end date2015-03-31
Total amount of commissions paid to insurance brokerUSD $1,688
Welfare Benefit Premiums Paid to CarrierUSD $27,265
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,688
Insurance broker organization code?3
Insurance broker nameJAY R SCHREIBMAN
BLUE CARE NETWORK OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 95610 )
Policy contract number00255278/0001
Policy instance 2
Insurance contract or identification number00255278/0001
Number of Individuals Covered379
Insurance policy start date2014-01-01
Insurance policy end date2014-03-31
Total amount of commissions paid to insurance brokerUSD $13,245
Welfare Benefit Premiums Paid to CarrierUSD $276,104
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $13,245
Insurance broker organization code?3
Insurance broker nameLUBIN SCHWARTZ & GOLDMAN INC
BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 )
Policy contract number62045-760
Policy instance 1
Insurance contract or identification number62045-760
Number of Individuals Covered5
Insurance policy start date2014-01-01
Insurance policy end date2014-03-31
Total amount of commissions paid to insurance brokerUSD $1,049
Welfare Benefit Premiums Paid to CarrierUSD $24,507
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,049
Insurance broker organization code?3
Insurance broker nameJAY R SCHREIBMAN
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number00402757
Policy instance 3
Insurance contract or identification number00402757
Number of Individuals Covered277
Insurance policy start date2014-01-01
Insurance policy end date2014-03-31
Total amount of commissions paid to insurance brokerUSD $4,090
Total amount of fees paid to insurance companyUSD $6,603
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $46,256
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,090
Amount paid for insurance broker fees6603
Insurance broker organization code?3
Insurance broker nameLUBIN SCHWARTZ & GOLDMAN INC
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number07294
Policy instance 4
Insurance contract or identification number07294
Number of Individuals Covered61
Insurance policy start date2014-01-01
Insurance policy end date2014-03-31
Total amount of commissions paid to insurance brokerUSD $515
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $3,434
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $515
Additional information about fees paid to insurance brokerSALES & SERVICE COMPENSATION
Insurance broker organization code?3
Insurance broker nameLUBIN SCHWARTZ & GOLDMAN INC
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number07294
Policy instance 3
Insurance contract or identification number07294
Number of Individuals Covered61
Insurance policy end date2013-12-31
Total amount of commissions paid to insurance brokerUSD $2,038
Long Term Disability Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,038
Insurance broker organization code?3
Insurance broker nameLUBIN, SCHWARTZ & GOLDMAN, INC
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number00402757
Policy instance 2
Insurance contract or identification number00402757
Number of Individuals Covered269
Insurance policy end date2014-03-31
Total amount of commissions paid to insurance brokerUSD $17,709
Total amount of fees paid to insurance companyUSD $6,603
Dental Insurance Welfare BenefitYes
Vision 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 $17,709
Amount paid for insurance broker fees6603
Additional information about fees paid to insurance brokerSALES & SERVICE COMPENSATION
Insurance broker organization code?3
Insurance broker nameLUBIN, SCHWARTZ & GOLDMAN, INC.
BLUE CARE NETWORK OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 95610 )
Policy contract number00255278/0001
Policy instance 1
Insurance contract or identification number00255278/0001
Number of Individuals Covered379
Insurance policy start date2013-04-01
Insurance policy end date2014-03-31
Total amount of commissions paid to insurance brokerUSD $58,825
Health Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $58,825
Insurance broker organization code?3
Insurance broker nameLUBIN, SCHWARTZ & GOLDMAN, INC
BLUE CARE NETWORK OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 95610 )
Policy contract number00255278/0001
Policy instance 1
Insurance contract or identification number00255278/0001
Number of Individuals Covered460
Insurance policy end date2013-03-31
Total amount of commissions paid to insurance brokerUSD $59,158
Health Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $59,158
Insurance broker organization code?3
Insurance broker nameLUBIN, SCHWARTZ & GOLDMAN, INC
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number07294
Policy instance 3
Insurance contract or identification number07294
Number of Individuals Covered82
Insurance policy end date2012-12-31
Total amount of commissions paid to insurance brokerUSD $1,820
Long Term Disability Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,820
Insurance broker organization code?3
Insurance broker nameLUBIN, SCHWARTZ & GOLDMAN, INC
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number00402757
Policy instance 2
Insurance contract or identification number00402757
Number of Individuals Covered320
Insurance policy end date2013-03-31
Total amount of commissions paid to insurance brokerUSD $18,439
Total amount of fees paid to insurance companyUSD $8,946
Dental Insurance Welfare BenefitYes
Vision 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 $18,439
Amount paid for insurance broker fees8946
Additional information about fees paid to insurance brokerSALES & SERVICE COMPENSATION
Insurance broker organization code?3
Insurance broker nameLUBIN, SCHWARTZ & GOLDMAN, INC.
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number07294
Policy instance 3
Insurance contract or identification number07294
Number of Individuals Covered78
Insurance policy end date2011-12-31
Total amount of commissions paid to insurance brokerUSD $1,538
Long Term Disability Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number00402757
Policy instance 2
Insurance contract or identification number00402757
Number of Individuals Covered261
Insurance policy end date2012-03-31
Total amount of commissions paid to insurance brokerUSD $14,119
Total amount of fees paid to insurance companyUSD $8,123
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
BLUE CARE NETWORK OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 95610 )
Policy contract number002552780001
Policy instance 1
Insurance contract or identification number002552780001
Number of Individuals Covered195
Insurance policy end date2012-02-29
Total amount of commissions paid to insurance brokerUSD $53,816
Health Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No

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