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PEPSI-COLA BOTTLING CO OF LACROSSE EMPLOYEE HEALTH AND WELFARE BENEFIT PLAN 401k Plan overview

Plan NamePEPSI-COLA BOTTLING CO OF LACROSSE EMPLOYEE HEALTH AND WELFARE BENEFIT PLAN
Plan identification number 501

PEPSI-COLA BOTTLING CO OF LACROSSE EMPLOYEE HEALTH AND WELFARE BENEFIT 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

PEPSI-COLA BOTTLING CO OF LA CROSSE has sponsored the creation of one or more 401k plans.

Company Name:PEPSI-COLA BOTTLING CO OF LA CROSSE
Employer identification number (EIN):390518767
NAIC Classification:424990
NAIC Description:Other Miscellaneous Nondurable Goods Merchant Wholesalers

Form 5500 Filing Information

Submission information for form 5500 for 401k plan PEPSI-COLA BOTTLING CO OF LACROSSE EMPLOYEE HEALTH AND WELFARE BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5012023-01-01
5012022-01-01
5012022-01-01
5012021-01-01
5012020-01-01
5012019-01-01
5012018-01-01BETTY ALDERMAN
5012017-01-01BETTY ALDERMAN
5012016-01-01BETTY ALDERMAN
5012015-01-01BETTY J ALDERMAN
5012014-01-01BETTY J ALDERMAN
5012013-01-01BETTY J. ALDERMAN
5012012-01-01BETTY ALDERMAN
5012011-01-01BETTY ALDERMAN BETTY ALDERMAN2012-05-22
5012010-01-01BETTY J. ALDERMAN BETTY J. ALDERMAN2011-07-27
5012009-01-01BETTY ALDERMAN BETTY ALDERMAN2010-07-28

Plan Statistics for PEPSI-COLA BOTTLING CO OF LACROSSE EMPLOYEE HEALTH AND WELFARE BENEFIT PLAN

401k plan membership statisitcs for PEPSI-COLA BOTTLING CO OF LACROSSE EMPLOYEE HEALTH AND WELFARE BENEFIT PLAN

Measure Date Value
2023: PEPSI-COLA BOTTLING CO OF LACROSSE EMPLOYEE HEALTH AND WELFARE BENEFIT PLAN 2023 401k membership
Total participants, beginning-of-year2023-01-01217
Total number of active participants reported on line 7a of the Form 55002023-01-01213
Number of retired or separated participants receiving benefits2023-01-011
Number of other retired or separated participants entitled to future benefits2023-01-010
Total of all active and inactive participants2023-01-01214
2022: PEPSI-COLA BOTTLING CO OF LACROSSE EMPLOYEE HEALTH AND WELFARE BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year2022-01-01217
Total number of active participants reported on line 7a of the Form 55002022-01-01215
Number of retired or separated participants receiving benefits2022-01-013
Number of other retired or separated participants entitled to future benefits2022-01-010
Total of all active and inactive participants2022-01-01218
2021: PEPSI-COLA BOTTLING CO OF LACROSSE EMPLOYEE HEALTH AND WELFARE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year2021-01-01189
Total number of active participants reported on line 7a of the Form 55002021-01-01193
Number of retired or separated participants receiving benefits2021-01-011
Total of all active and inactive participants2021-01-01194
Total participants2021-01-01194
2020: PEPSI-COLA BOTTLING CO OF LACROSSE EMPLOYEE HEALTH AND WELFARE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year2020-01-01272
Total number of active participants reported on line 7a of the Form 55002020-01-01261
Number of retired or separated participants receiving benefits2020-01-013
Total of all active and inactive participants2020-01-01264
Total participants2020-01-01264
2019: PEPSI-COLA BOTTLING CO OF LACROSSE EMPLOYEE HEALTH AND WELFARE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year2019-01-01273
Total number of active participants reported on line 7a of the Form 55002019-01-01268
Number of retired or separated participants receiving benefits2019-01-012
Total of all active and inactive participants2019-01-01270
Total participants2019-01-01270
2018: PEPSI-COLA BOTTLING CO OF LACROSSE EMPLOYEE HEALTH AND WELFARE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year2018-01-01285
Total number of active participants reported on line 7a of the Form 55002018-01-01273
Number of retired or separated participants receiving benefits2018-01-015
Total of all active and inactive participants2018-01-01278
2017: PEPSI-COLA BOTTLING CO OF LACROSSE EMPLOYEE HEALTH AND WELFARE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year2017-01-01276
Total number of active participants reported on line 7a of the Form 55002017-01-01279
Number of retired or separated participants receiving benefits2017-01-012
Total of all active and inactive participants2017-01-01281
2016: PEPSI-COLA BOTTLING CO OF LACROSSE EMPLOYEE HEALTH AND WELFARE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year2016-01-01269
Total number of active participants reported on line 7a of the Form 55002016-01-01268
Number of retired or separated participants receiving benefits2016-01-011
Total of all active and inactive participants2016-01-01269
2015: PEPSI-COLA BOTTLING CO OF LACROSSE EMPLOYEE HEALTH AND WELFARE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year2015-01-01270
Total number of active participants reported on line 7a of the Form 55002015-01-01265
Number of retired or separated participants receiving benefits2015-01-012
Number of other retired or separated participants entitled to future benefits2015-01-010
Total of all active and inactive participants2015-01-01267
2014: PEPSI-COLA BOTTLING CO OF LACROSSE EMPLOYEE HEALTH AND WELFARE BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year2014-01-01261
Total number of active participants reported on line 7a of the Form 55002014-01-01264
Number of retired or separated participants receiving benefits2014-01-016
Number of other retired or separated participants entitled to future benefits2014-01-010
Total of all active and inactive participants2014-01-01270
2013: PEPSI-COLA BOTTLING CO OF LACROSSE EMPLOYEE HEALTH AND WELFARE BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year2013-01-01258
Total number of active participants reported on line 7a of the Form 55002013-01-01255
Number of retired or separated participants receiving benefits2013-01-016
Number of other retired or separated participants entitled to future benefits2013-01-010
Total of all active and inactive participants2013-01-01261
2012: PEPSI-COLA BOTTLING CO OF LACROSSE EMPLOYEE HEALTH AND WELFARE BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year2012-01-01250
Total number of active participants reported on line 7a of the Form 55002012-01-01258
Number of retired or separated participants receiving benefits2012-01-016
Number of other retired or separated participants entitled to future benefits2012-01-010
Total of all active and inactive participants2012-01-01264
2011: PEPSI-COLA BOTTLING CO OF LACROSSE EMPLOYEE HEALTH AND WELFARE BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year2011-01-01275
Total number of active participants reported on line 7a of the Form 55002011-01-01244
Number of retired or separated participants receiving benefits2011-01-016
Number of other retired or separated participants entitled to future benefits2011-01-010
Total of all active and inactive participants2011-01-01250
2010: PEPSI-COLA BOTTLING CO OF LACROSSE EMPLOYEE HEALTH AND WELFARE BENEFIT PLAN 2010 401k membership
Total participants, beginning-of-year2010-01-01280
Total number of active participants reported on line 7a of the Form 55002010-01-01275
Number of retired or separated participants receiving benefits2010-01-013
Number of other retired or separated participants entitled to future benefits2010-01-010
Total of all active and inactive participants2010-01-01278
2009: PEPSI-COLA BOTTLING CO OF LACROSSE EMPLOYEE HEALTH AND WELFARE BENEFIT PLAN 2009 401k membership
Total participants, beginning-of-year2009-01-01289
Total number of active participants reported on line 7a of the Form 55002009-01-01280
Number of retired or separated participants receiving benefits2009-01-014
Number of other retired or separated participants entitled to future benefits2009-01-010
Total of all active and inactive participants2009-01-01284

Form 5500 Responses for PEPSI-COLA BOTTLING CO OF LACROSSE EMPLOYEE HEALTH AND WELFARE BENEFIT PLAN

2023: PEPSI-COLA BOTTLING CO OF LACROSSE EMPLOYEE HEALTH AND WELFARE BENEFIT PLAN 2023 form 5500 responses
2023-01-01Type of plan entitySingle employer plan
2023-01-01Submission has been amendedNo
2023-01-01This submission is the final filingNo
2023-01-01This return/report is a short plan year return/report (less than 12 months)No
2023-01-01Plan is a collectively bargained planNo
2023-01-01Plan funding arrangement – InsuranceYes
2023-01-01Plan funding arrangement – General assets of the sponsorYes
2023-01-01Plan benefit arrangement – InsuranceYes
2023-01-01Plan benefit arrangement – General assets of the sponsorYes
2022: PEPSI-COLA BOTTLING CO OF LACROSSE EMPLOYEE HEALTH AND WELFARE BENEFIT PLAN 2022 form 5500 responses
2022-01-01Type of plan entitySingle employer plan
2022-01-01Submission has been amendedNo
2022-01-01This submission is the final filingNo
2022-01-01This return/report is a short plan year return/report (less than 12 months)No
2022-01-01Plan is a collectively bargained planNo
2022-01-01Plan funding arrangement – InsuranceYes
2022-01-01Plan funding arrangement – General assets of the sponsorYes
2022-01-01Plan benefit arrangement – InsuranceYes
2022-01-01Plan benefit arrangement – General assets of the sponsorYes
2021: PEPSI-COLA BOTTLING CO OF LACROSSE EMPLOYEE HEALTH AND WELFARE BENEFIT PLAN 2021 form 5500 responses
2021-01-01Type of plan entitySingle employer plan
2021-01-01Submission has been amendedNo
2021-01-01This submission is the final filingNo
2021-01-01This return/report is a short plan year return/report (less than 12 months)No
2021-01-01Plan is a collectively bargained planNo
2021-01-01Plan funding arrangement – InsuranceYes
2021-01-01Plan funding arrangement – General assets of the sponsorYes
2021-01-01Plan benefit arrangement – InsuranceYes
2021-01-01Plan benefit arrangement – General assets of the sponsorYes
2020: PEPSI-COLA BOTTLING CO OF LACROSSE EMPLOYEE HEALTH AND WELFARE BENEFIT PLAN 2020 form 5500 responses
2020-01-01Type of plan entitySingle employer plan
2020-01-01Submission has been amendedNo
2020-01-01This submission is the final filingNo
2020-01-01This return/report is a short plan year return/report (less than 12 months)No
2020-01-01Plan is a collectively bargained planNo
2020-01-01Plan funding arrangement – InsuranceYes
2020-01-01Plan funding arrangement – General assets of the sponsorYes
2020-01-01Plan benefit arrangement – InsuranceYes
2020-01-01Plan benefit arrangement – General assets of the sponsorYes
2019: PEPSI-COLA BOTTLING CO OF LACROSSE EMPLOYEE HEALTH AND WELFARE BENEFIT PLAN 2019 form 5500 responses
2019-01-01Type of plan entitySingle employer plan
2019-01-01Submission has been amendedNo
2019-01-01This submission is the final filingNo
2019-01-01This return/report is a short plan year return/report (less than 12 months)No
2019-01-01Plan is a collectively bargained planNo
2019-01-01Plan funding arrangement – InsuranceYes
2019-01-01Plan funding arrangement – General assets of the sponsorYes
2019-01-01Plan benefit arrangement – InsuranceYes
2019-01-01Plan benefit arrangement – General assets of the sponsorYes
2018: PEPSI-COLA BOTTLING CO OF LACROSSE EMPLOYEE HEALTH AND WELFARE BENEFIT PLAN 2018 form 5500 responses
2018-01-01Type of plan entitySingle employer plan
2018-01-01Submission has been amendedNo
2018-01-01This submission is the final filingNo
2018-01-01This return/report is a short plan year return/report (less than 12 months)No
2018-01-01Plan is a collectively bargained planNo
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: PEPSI-COLA BOTTLING CO OF LACROSSE EMPLOYEE HEALTH AND WELFARE BENEFIT PLAN 2017 form 5500 responses
2017-01-01Type of plan entitySingle employer plan
2017-01-01Submission has been amendedNo
2017-01-01This submission is the final filingNo
2017-01-01This return/report is a short plan year return/report (less than 12 months)No
2017-01-01Plan is a collectively bargained planNo
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: PEPSI-COLA BOTTLING CO OF LACROSSE EMPLOYEE HEALTH AND WELFARE BENEFIT PLAN 2016 form 5500 responses
2016-01-01Type of plan entitySingle employer plan
2016-01-01Submission has been amendedNo
2016-01-01This submission is the final filingNo
2016-01-01This return/report is a short plan year return/report (less than 12 months)No
2016-01-01Plan is a collectively bargained planNo
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: PEPSI-COLA BOTTLING CO OF LACROSSE EMPLOYEE HEALTH AND WELFARE BENEFIT PLAN 2015 form 5500 responses
2015-01-01Type of plan entitySingle employer plan
2015-01-01Submission has been amendedNo
2015-01-01This submission is the final filingNo
2015-01-01This return/report is a short plan year return/report (less than 12 months)No
2015-01-01Plan is a collectively bargained planNo
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: PEPSI-COLA BOTTLING CO OF LACROSSE EMPLOYEE HEALTH AND WELFARE BENEFIT PLAN 2014 form 5500 responses
2014-01-01Type of plan entitySingle employer plan
2014-01-01Submission has been amendedNo
2014-01-01This submission is the final filingNo
2014-01-01This return/report is a short plan year return/report (less than 12 months)No
2014-01-01Plan is a collectively bargained planNo
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: PEPSI-COLA BOTTLING CO OF LACROSSE EMPLOYEE HEALTH AND WELFARE BENEFIT PLAN 2013 form 5500 responses
2013-01-01Type of plan entitySingle employer plan
2013-01-01Submission has been amendedNo
2013-01-01This submission is the final filingNo
2013-01-01This return/report is a short plan year return/report (less than 12 months)No
2013-01-01Plan is a collectively bargained planNo
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: PEPSI-COLA BOTTLING CO OF LACROSSE EMPLOYEE HEALTH AND WELFARE BENEFIT PLAN 2012 form 5500 responses
2012-01-01Type of plan entitySingle employer plan
2012-01-01Submission has been amendedNo
2012-01-01This submission is the final filingNo
2012-01-01This return/report is a short plan year return/report (less than 12 months)No
2012-01-01Plan is a collectively bargained planNo
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: PEPSI-COLA BOTTLING CO OF LACROSSE EMPLOYEE HEALTH AND WELFARE BENEFIT PLAN 2011 form 5500 responses
2011-01-01Type of plan entitySingle employer plan
2011-01-01Submission has been amendedNo
2011-01-01This submission is the final filingNo
2011-01-01This return/report is a short plan year return/report (less than 12 months)No
2011-01-01Plan is a collectively bargained planNo
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
2010: PEPSI-COLA BOTTLING CO OF LACROSSE EMPLOYEE HEALTH AND WELFARE BENEFIT PLAN 2010 form 5500 responses
2010-01-01Type of plan entitySingle employer plan
2010-01-01Submission has been amendedNo
2010-01-01This submission is the final filingNo
2010-01-01This return/report is a short plan year return/report (less than 12 months)No
2010-01-01Plan is a collectively bargained planNo
2010-01-01Plan funding arrangement – InsuranceYes
2010-01-01Plan funding arrangement – General assets of the sponsorYes
2010-01-01Plan benefit arrangement – InsuranceYes
2010-01-01Plan benefit arrangement – General assets of the sponsorYes
2009: PEPSI-COLA BOTTLING CO OF LACROSSE EMPLOYEE HEALTH AND WELFARE BENEFIT PLAN 2009 form 5500 responses
2009-01-01Type of plan entitySingle employer plan
2009-01-01Submission has been amendedNo
2009-01-01This submission is the final filingNo
2009-01-01This return/report is a short plan year return/report (less than 12 months)No
2009-01-01Plan is a collectively bargained planNo
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

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number805751G
Policy instance 2
Insurance contract or identification number805751G
Number of Individuals Covered286
Insurance policy start date2023-01-01
Insurance policy end date2023-12-31
Total amount of commissions paid to insurance brokerUSD $18,129
Total amount of fees paid to insurance companyUSD $1,742
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare 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 providedAD&D
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $100,395
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
WYSSTA INSURANCE COMPANY INC. (National Association of Insurance Commissioners NAIC id number: 12352 )
Policy contract number43988
Policy instance 1
Insurance contract or identification number43988
Number of Individuals Covered137
Insurance policy start date2023-01-01
Insurance policy end date2023-12-31
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $14,240
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
WYSSTA INSURANCE COMPANY INC. (National Association of Insurance Commissioners NAIC id number: 12352 )
Policy contract number43988 00000
Policy instance 2
Insurance contract or identification number43988 00000
Number of Individuals Covered138
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $15,139
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number805751G
Policy instance 1
Insurance contract or identification number805751G
Number of Individuals Covered279
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $20,899
Total amount of fees paid to insurance companyUSD $557
Life Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $116,103
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $20,899
Amount paid for insurance broker fees557
Additional information about fees paid to insurance brokerBONUS
Insurance broker organization code?3
SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )
Policy contract number943033
Policy instance 3
Insurance contract or identification number943033
Number of Individuals Covered195
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $13,417
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $366,069
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $10,063
Insurance broker organization code?3
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number805751G
Policy instance 2
Insurance contract or identification number805751G
Number of Individuals Covered260
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $15,917
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare 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 providedAD&D
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $95,563
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $15,917
Insurance broker organization code?3
WYSSTA INSURANCE COMPANY INC. (National Association of Insurance Commissioners NAIC id number: 12352 )
Policy contract number43988
Policy instance 1
Insurance contract or identification number43988
Number of Individuals Covered125
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $13,416
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number0686266
Policy instance 1
Insurance contract or identification number0686266
Number of Individuals Covered261
Insurance policy start date2020-01-01
Insurance policy end date2020-05-31
Total amount of commissions paid to insurance brokerUSD $4,972
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare 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 providedAD&D
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $35,720
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,972
Insurance broker organization code?3
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number805751G
Policy instance 2
Insurance contract or identification number805751G
Number of Individuals Covered253
Insurance policy start date2020-06-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $6,399
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare 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 providedAD&D
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $28,411
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6,399
Insurance broker organization code?3
HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93340 )
Policy contract number540345
Policy instance 3
Insurance contract or identification number540345
Number of Individuals Covered110
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $1,477
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $14,785
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,477
Insurance broker organization code?3
BLUE CROSS BLUE SHIELD OF WISCONSIN (National Association of Insurance Commissioners NAIC id number: 54003 )
Policy contract numberWI2026
Policy instance 4
Insurance contract or identification numberWI2026
Number of Individuals Covered442
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $268,198
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93340 )
Policy contract number540345 0010
Policy instance 3
Insurance contract or identification number540345 0010
Number of Individuals Covered112
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $428
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $4,281
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $428
Insurance broker organization code?3
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number0686266
Policy instance 2
Insurance contract or identification number0686266
Number of Individuals Covered268
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $15,019
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare 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 providedAD&D
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $85,092
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $15,019
Insurance broker organization code?3
BLUE CROSS BLUE SHIELD OF WISCONSIN (National Association of Insurance Commissioners NAIC id number: 54003 )
Policy contract numberWI2026
Policy instance 1
Insurance contract or identification numberWI2026
Number of Individuals Covered469
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $261,056
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
BCBSM, INC. DBA BLUE CROSS AND BLUE SHIELD OF MINNESOTA (National Association of Insurance Commissioners NAIC id number: 55026 )
Policy contract numberEP979/201283
Policy instance 3
Insurance contract or identification numberEP979/201283
Number of Individuals Covered498
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Welfare Benefit Premiums Paid to CarrierUSD $272,276
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number0686266
Policy instance 2
Insurance contract or identification number0686266
Number of Individuals Covered273
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $14,308
Total amount of fees paid to insurance companyUSD $0
Life Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $81,037
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $14,308
Insurance broker organization code?3
HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93340 )
Policy contract number540345 0010-50
Policy instance 1
Insurance contract or identification number540345 0010-50
Number of Individuals Covered110
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $1,593
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $15,964
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,593
Insurance broker organization code?3
HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93340 )
Policy contract number540345 0010-50
Policy instance 3
Insurance contract or identification number540345 0010-50
Number of Individuals Covered107
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $1,539
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $15,390
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $395
Insurance broker organization code?3
Insurance broker nameM3 INSURANCE SOLUTIONS, INC.
BCBSM, INC. DBA BLUE CROSS AND BLUE SHIELD OF MINNESOTA (National Association of Insurance Commissioners NAIC id number: 55026 )
Policy contract numberEP979/201283
Policy instance 2
Insurance contract or identification numberEP979/201283
Number of Individuals Covered502
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $38,961
Total amount of fees paid to insurance companyUSD $6,552
Welfare Benefit Premiums Paid to CarrierUSD $278,825
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $38,961
Amount paid for insurance broker fees6552
Additional information about fees paid to insurance brokerINCENTIVE PAYMENTS
Insurance broker organization code?3
Insurance broker nameMERCER HEALTH BENEFITS LLC
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number0686266
Policy instance 1
Insurance contract or identification number0686266
Number of Individuals Covered279
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $14,045
Total amount of fees paid to insurance companyUSD $0
Life Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $79,684
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,770
Insurance broker organization code?3
Insurance broker nameMERCER HEALTH AND BENEFITS LLC
HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93340 )
Policy contract number540345
Policy instance 4
Insurance contract or identification number540345
Number of Individuals Covered99
Insurance policy start date2015-01-01
Insurance policy end date2015-12-31
Total amount of commissions paid to insurance brokerUSD $1,459
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $14,594
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,459
Insurance broker organization code?3
Insurance broker nameMERCER HEALTH AND BENEFITS, LLC
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number0686266
Policy instance 3
Insurance contract or identification number0686266
Number of Individuals Covered121
Insurance policy start date2015-01-01
Insurance policy end date2015-12-31
Total amount of commissions paid to insurance brokerUSD $2,691
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $15,308
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,691
Insurance broker organization code?3
Insurance broker nameMERCER HEALTH AND BENEFITS, LLC
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number0686266
Policy instance 2
Insurance contract or identification number0686266
Number of Individuals Covered270
Insurance policy start date2015-01-01
Insurance policy end date2015-12-31
Total amount of commissions paid to insurance brokerUSD $10,436
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $64,148
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $10,436
Insurance broker organization code?3
Insurance broker nameMERCER HEALTH AND BENEFITS, LLC
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number0686266
Policy instance 1
Insurance contract or identification number0686266
Number of Individuals Covered270
Insurance policy start date2015-01-01
Insurance policy end date2015-12-31
Total amount of commissions paid to insurance brokerUSD $380
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $3,721
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $380
Insurance broker organization code?3
Insurance broker nameMERCER HEALTH AND BENEFITS, LLC
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract numberGL150680
Policy instance 1
Insurance contract or identification numberGL150680
Number of Individuals Covered263
Insurance policy start date2014-01-01
Insurance policy end date2014-12-31
Total amount of commissions paid to insurance brokerUSD $13,359
Total amount of fees paid to insurance companyUSD $2,948
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $74,218
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $13,359
Amount paid for insurance broker fees2948
Additional information about fees paid to insurance brokerADMINISTRATIVE FEES
Insurance broker organization code?3
Insurance broker nameMERCER HEALTH AND BENEFITS, LLC
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract numberLTD 123611
Policy instance 2
Insurance contract or identification numberLTD 123611
Number of Individuals Covered20
Insurance policy start date2014-01-01
Insurance policy end date2014-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $307
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $7,279
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Amount paid for insurance broker fees307
Additional information about fees paid to insurance brokerADMINISTRATIVE FEES
Insurance broker organization code?3
Insurance broker nameMERCER HEALTH AND BENEFITS, LLC
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract numberVPL301181
Policy instance 3
Insurance contract or identification numberVPL301181
Number of Individuals Covered108
Insurance policy start date2014-01-01
Insurance policy end date2014-12-31
Total amount of commissions paid to insurance brokerUSD $4,247
Total amount of fees paid to insurance companyUSD $736
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $17,697
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,247
Amount paid for insurance broker fees736
Additional information about fees paid to insurance brokerADMINISTRATIVE FEES
Insurance broker organization code?3
Insurance broker nameMERCER HEALTH AND BENEFITS, LLC
HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93340 )
Policy contract number540345
Policy instance 4
Insurance contract or identification number540345
Number of Individuals Covered91
Insurance policy start date2014-01-01
Insurance policy end date2014-12-31
Total amount of commissions paid to insurance brokerUSD $1,248
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $12,477
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,248
Insurance broker organization code?3
Insurance broker nameMERCER HEALTH AND BENEFITS, LLC
HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93340 )
Policy contract number540345
Policy instance 4
Insurance contract or identification number540345
Number of Individuals Covered81
Insurance policy start date2013-01-01
Insurance policy end date2013-12-31
Total amount of commissions paid to insurance brokerUSD $1,157
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $11,568
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,157
Insurance broker organization code?3
Insurance broker nameMERCER HEALTH AND BENEFITS, LLC
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract numberVPL301181
Policy instance 3
Insurance contract or identification numberVPL301181
Number of Individuals Covered108
Insurance policy start date2013-01-01
Insurance policy end date2013-12-31
Total amount of commissions paid to insurance brokerUSD $4,416
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $18,576
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,416
Insurance broker organization code?3
Insurance broker nameMERCER HEALTH AND BENEFITS, LLC
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract numberLTD123611
Policy instance 2
Insurance contract or identification numberLTD123611
Number of Individuals Covered20
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
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $7,677
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract numberGL150680
Policy instance 1
Insurance contract or identification numberGL150680
Number of Individuals Covered263
Insurance policy start date2013-01-01
Insurance policy end date2013-12-31
Total amount of commissions paid to insurance brokerUSD $13,264
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $73,690
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $13,264
Insurance broker organization code?3
Insurance broker nameMERCER HEALTH AND BENEFITS, LLC
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number00340
Policy instance 1
Insurance contract or identification number00340
Number of Individuals Covered257
Insurance policy start date2012-01-01
Insurance policy end date2012-12-31
Total amount of commissions paid to insurance brokerUSD $19,417
Total amount of fees paid to insurance companyUSD $960
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare 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
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $107,876
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $19,417
Amount paid for insurance broker fees960
Additional information about fees paid to insurance brokerSUPPLEMENTAL COMMISSIONS
Insurance broker organization code?3
Insurance broker nameMERCER HEALTH & BENEFITS LLC
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number00340
Policy instance 1
Insurance contract or identification number00340
Number of Individuals Covered263
Insurance policy start date2011-01-01
Insurance policy end date2011-12-31
Total amount of commissions paid to insurance brokerUSD $19,675
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare 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 providedAD & D
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $106,380
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number00340
Policy instance 1
Insurance contract or identification number00340
Number of Individuals Covered275
Insurance policy start date2010-01-01
Insurance policy end date2010-12-31
Total amount of commissions paid to insurance brokerUSD $21,437
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare 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 providedAD & D
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $104,628
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $18,833
Insurance broker organization code?3
Insurance broker nameMERCER HEALTH & BENEFITS LLC

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