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CAPITOL INDEMNITY CORPORATION HEALTH AND WELFARE BENEFIT PLAN 401k Plan overview

Plan NameCAPITOL INDEMNITY CORPORATION HEALTH AND WELFARE BENEFIT PLAN
Plan identification number 501

CAPITOL INDEMNITY CORPORATION 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

CAPITOL INDEMNITY CORPORATION has sponsored the creation of one or more 401k plans.

Company Name:CAPITOL INDEMNITY CORPORATION
Employer identification number (EIN):390971527
NAIC Classification:524150

Additional information about CAPITOL INDEMNITY CORPORATION

Jurisdiction of Incorporation: Georgia Department of States Corporations Division
Incorporation Date: 2004-12-08
Company Identification Number: 1204560
Legal Registered Office Address: 1600 ASPEN COMMONS

MIDDLETON
United States of America (USA)
53562

More information about CAPITOL INDEMNITY CORPORATION

Form 5500 Filing Information

Submission information for form 5500 for 401k plan CAPITOL INDEMNITY CORPORATION HEALTH AND WELFARE BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5012022-01-01LYNNE FLETCHER2023-07-28
5012021-01-01JENNAI S. WILLIAMS2022-07-27
5012020-01-01JENNAI S. WILLIAMS2021-08-03
5012019-01-01HAYLEY L. HELLENBRAND2020-07-23
5012018-03-01HAYLEY L. HELLENBRAND2019-09-17
5012017-03-01
5012016-03-01HAYLEY HELLENBRAND
5012015-03-01HAYLEY HELLENBRAND
5012014-03-01HAYLEY HELLENBRAND
5012013-03-01SARA MILLAR
5012012-03-01SARA MILLAR
5012011-03-01DIANE M. WEST
5012010-03-01DIANE M. WEST
5012009-03-01DIANE M. WEST

Plan Statistics for CAPITOL INDEMNITY CORPORATION HEALTH AND WELFARE BENEFIT PLAN

401k plan membership statisitcs for CAPITOL INDEMNITY CORPORATION HEALTH AND WELFARE BENEFIT PLAN

Measure Date Value
2022: CAPITOL INDEMNITY CORPORATION HEALTH AND WELFARE BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year2022-01-01311
Total number of active participants reported on line 7a of the Form 55002022-01-01309
Number of retired or separated participants receiving benefits2022-01-016
Number of other retired or separated participants entitled to future benefits2022-01-0110
Total of all active and inactive participants2022-01-01325
Number of employers contributing to the scheme2022-01-010
2021: CAPITOL INDEMNITY CORPORATION HEALTH AND WELFARE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year2021-01-01296
Total number of active participants reported on line 7a of the Form 55002021-01-01293
Number of retired or separated participants receiving benefits2021-01-017
Number of other retired or separated participants entitled to future benefits2021-01-0111
Total of all active and inactive participants2021-01-01311
Number of employers contributing to the scheme2021-01-010
2020: CAPITOL INDEMNITY CORPORATION HEALTH AND WELFARE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year2020-01-01332
Total number of active participants reported on line 7a of the Form 55002020-01-01296
Number of retired or separated participants receiving benefits2020-01-017
Number of other retired or separated participants entitled to future benefits2020-01-0118
Total of all active and inactive participants2020-01-01321
Number of employers contributing to the scheme2020-01-010
2019: CAPITOL INDEMNITY CORPORATION HEALTH AND WELFARE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year2019-01-01333
Total number of active participants reported on line 7a of the Form 55002019-01-01332
Number of retired or separated participants receiving benefits2019-01-011
Number of other retired or separated participants entitled to future benefits2019-01-019
Total of all active and inactive participants2019-01-01342
Number of employers contributing to the scheme2019-01-010
2018: CAPITOL INDEMNITY CORPORATION HEALTH AND WELFARE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year2018-03-01320
Total number of active participants reported on line 7a of the Form 55002018-03-01326
Number of retired or separated participants receiving benefits2018-03-017
Number of other retired or separated participants entitled to future benefits2018-03-010
Total of all active and inactive participants2018-03-01333
Number of employers contributing to the scheme2018-03-010
2017: CAPITOL INDEMNITY CORPORATION HEALTH AND WELFARE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year2017-03-01291
Total number of active participants reported on line 7a of the Form 55002017-03-01316
Number of retired or separated participants receiving benefits2017-03-014
Number of other retired or separated participants entitled to future benefits2017-03-010
Total of all active and inactive participants2017-03-01320
2016: CAPITOL INDEMNITY CORPORATION HEALTH AND WELFARE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year2016-03-01235
Total number of active participants reported on line 7a of the Form 55002016-03-01291
Number of retired or separated participants receiving benefits2016-03-010
Number of other retired or separated participants entitled to future benefits2016-03-010
Total of all active and inactive participants2016-03-01291
2015: CAPITOL INDEMNITY CORPORATION HEALTH AND WELFARE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year2015-03-01229
Total number of active participants reported on line 7a of the Form 55002015-03-01235
Number of retired or separated participants receiving benefits2015-03-010
Number of other retired or separated participants entitled to future benefits2015-03-010
Total of all active and inactive participants2015-03-01235
2014: CAPITOL INDEMNITY CORPORATION HEALTH AND WELFARE BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year2014-03-01237
Total number of active participants reported on line 7a of the Form 55002014-03-01229
Number of retired or separated participants receiving benefits2014-03-010
Number of other retired or separated participants entitled to future benefits2014-03-010
Total of all active and inactive participants2014-03-01229
2013: CAPITOL INDEMNITY CORPORATION HEALTH AND WELFARE BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year2013-03-01216
Total number of active participants reported on line 7a of the Form 55002013-03-01237
Number of retired or separated participants receiving benefits2013-03-010
Number of other retired or separated participants entitled to future benefits2013-03-010
Total of all active and inactive participants2013-03-01237
2012: CAPITOL INDEMNITY CORPORATION HEALTH AND WELFARE BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year2012-03-01176
Total number of active participants reported on line 7a of the Form 55002012-03-01216
Number of retired or separated participants receiving benefits2012-03-010
Number of other retired or separated participants entitled to future benefits2012-03-010
Total of all active and inactive participants2012-03-01216
2011: CAPITOL INDEMNITY CORPORATION HEALTH AND WELFARE BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year2011-03-01332
Total number of active participants reported on line 7a of the Form 55002011-03-01325
Total of all active and inactive participants2011-03-01325
2010: CAPITOL INDEMNITY CORPORATION HEALTH AND WELFARE BENEFIT PLAN 2010 401k membership
Total participants, beginning-of-year2010-03-01325
Total number of active participants reported on line 7a of the Form 55002010-03-01332
Total of all active and inactive participants2010-03-01332
2009: CAPITOL INDEMNITY CORPORATION HEALTH AND WELFARE BENEFIT PLAN 2009 401k membership
Total participants, beginning-of-year2009-03-01329
Total number of active participants reported on line 7a of the Form 55002009-03-01325
Total of all active and inactive participants2009-03-01325

Form 5500 Responses for CAPITOL INDEMNITY CORPORATION HEALTH AND WELFARE BENEFIT PLAN

2022: CAPITOL INDEMNITY CORPORATION HEALTH AND WELFARE BENEFIT PLAN 2022 form 5500 responses
2022-01-01Type of plan entitySingle employer plan
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: CAPITOL INDEMNITY CORPORATION HEALTH AND WELFARE BENEFIT PLAN 2021 form 5500 responses
2021-01-01Type of plan entitySingle employer plan
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: CAPITOL INDEMNITY CORPORATION HEALTH AND WELFARE BENEFIT PLAN 2020 form 5500 responses
2020-01-01Type of plan entitySingle employer plan
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: CAPITOL INDEMNITY CORPORATION HEALTH AND WELFARE BENEFIT PLAN 2019 form 5500 responses
2019-01-01Type of plan entitySingle employer plan
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: CAPITOL INDEMNITY CORPORATION HEALTH AND WELFARE BENEFIT PLAN 2018 form 5500 responses
2018-03-01Type of plan entitySingle employer plan
2018-03-01This return/report is a short plan year return/report (less than 12 months)Yes
2018-03-01Plan funding arrangement – InsuranceYes
2018-03-01Plan funding arrangement – General assets of the sponsorYes
2018-03-01Plan benefit arrangement – InsuranceYes
2018-03-01Plan benefit arrangement – General assets of the sponsorYes
2017: CAPITOL INDEMNITY CORPORATION HEALTH AND WELFARE BENEFIT PLAN 2017 form 5500 responses
2017-03-01Type of plan entitySingle employer plan
2017-03-01Plan funding arrangement – InsuranceYes
2017-03-01Plan benefit arrangement – InsuranceYes
2016: CAPITOL INDEMNITY CORPORATION HEALTH AND WELFARE BENEFIT PLAN 2016 form 5500 responses
2016-03-01Type of plan entitySingle employer plan
2016-03-01Plan funding arrangement – InsuranceYes
2016-03-01Plan benefit arrangement – InsuranceYes
2015: CAPITOL INDEMNITY CORPORATION HEALTH AND WELFARE BENEFIT PLAN 2015 form 5500 responses
2015-03-01Type of plan entitySingle employer plan
2015-03-01Plan funding arrangement – InsuranceYes
2015-03-01Plan benefit arrangement – InsuranceYes
2014: CAPITOL INDEMNITY CORPORATION HEALTH AND WELFARE BENEFIT PLAN 2014 form 5500 responses
2014-03-01Type of plan entitySingle employer plan
2014-03-01Plan funding arrangement – InsuranceYes
2014-03-01Plan benefit arrangement – InsuranceYes
2013: CAPITOL INDEMNITY CORPORATION HEALTH AND WELFARE BENEFIT PLAN 2013 form 5500 responses
2013-03-01Type of plan entitySingle employer plan
2013-03-01Submission has been amendedNo
2013-03-01This submission is the final filingNo
2013-03-01This return/report is a short plan year return/report (less than 12 months)No
2013-03-01Plan is a collectively bargained planNo
2013-03-01Plan funding arrangement – InsuranceYes
2013-03-01Plan benefit arrangement – InsuranceYes
2012: CAPITOL INDEMNITY CORPORATION HEALTH AND WELFARE BENEFIT PLAN 2012 form 5500 responses
2012-03-01Type of plan entitySingle employer plan
2012-03-01Submission has been amendedYes
2012-03-01This submission is the final filingNo
2012-03-01This return/report is a short plan year return/report (less than 12 months)No
2012-03-01Plan is a collectively bargained planNo
2012-03-01Plan funding arrangement – InsuranceYes
2012-03-01Plan benefit arrangement – InsuranceYes
2011: CAPITOL INDEMNITY CORPORATION HEALTH AND WELFARE BENEFIT PLAN 2011 form 5500 responses
2011-03-01Type of plan entitySingle employer plan
2011-03-01Plan funding arrangement – InsuranceYes
2011-03-01Plan benefit arrangement – InsuranceYes
2010: CAPITOL INDEMNITY CORPORATION HEALTH AND WELFARE BENEFIT PLAN 2010 form 5500 responses
2010-03-01Type of plan entitySingle employer plan
2010-03-01Plan funding arrangement – InsuranceYes
2010-03-01Plan benefit arrangement – InsuranceYes
2009: CAPITOL INDEMNITY CORPORATION HEALTH AND WELFARE BENEFIT PLAN 2009 form 5500 responses
2009-03-01Type of plan entitySingle employer plan
2009-03-01This submission is the final filingNo
2009-03-01Plan funding arrangement – InsuranceYes
2009-03-01Plan benefit arrangement – InsuranceYes

Insurance Providers Used on plan

BLUE CROSS BLUE SHIELD OF WISCONSIN (National Association of Insurance Commissioners NAIC id number: 54003 )
Policy contract numberW12267
Policy instance 2
Insurance contract or identification numberW12267
Number of Individuals Covered366
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $20,559
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $2,758,044
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $20,559
Amount paid for insurance broker fees0
Insurance broker organization code?3
DEAN HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 96156 )
Policy contract number1754
Policy instance 1
Insurance contract or identification number1754
Number of Individuals Covered183
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $19,044
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,484,850
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $19,044
Amount paid for insurance broker fees0
Insurance broker organization code?3
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number5944742
Policy instance 3
Insurance contract or identification number5944742
Number of Individuals Covered876
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $6,082
Total amount of fees paid to insurance companyUSD $5,080
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $250,223
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6,082
Amount paid for insurance broker fees87
Additional information about fees paid to insurance brokerNON-MONETARY COMPENSATION
Insurance broker organization code?3
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number30039791
Policy instance 4
Insurance contract or identification number30039791
Number of Individuals Covered211
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $1,445
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $35,423
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,445
Amount paid for insurance broker fees0
Insurance broker organization code?3
EMPATHIA, INC. (National Association of Insurance Commissioners NAIC id number: 62419 )
Policy contract number00
Policy instance 5
Insurance contract or identification number00
Number of Individuals Covered309
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedEMPLOYEE ASSISTANCE PROGRAM
Welfare Benefit Premiums Paid to CarrierUSD $6,588
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
RELIASTAR LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 67105 )
Policy contract number724599
Policy instance 6
Insurance contract or identification number724599
Number of Individuals Covered162
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $10,132
Total amount of fees paid to insurance companyUSD $1,793
Other welfare benefits providedACCIDENT, CRITICAL ILLNESS, HOSPITAL
Welfare Benefit Premiums Paid to CarrierUSD $47,419
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $9,484
Amount paid for insurance broker fees1793
Additional information about fees paid to insurance brokerSUPPLEMENTAL COMPENSATION
Insurance broker organization code?3
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract numberGL162916
Policy instance 7
Insurance contract or identification numberGL162916
Number of Individuals Covered293
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $11,880
Total amount of fees paid to insurance companyUSD $2,785
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $214,098
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $11,880
Amount paid for insurance broker fees2783
Additional information about fees paid to insurance brokerADMINISTRATIVE AND OTHER FEES
Insurance broker organization code?3
DEAN HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 96156 )
Policy contract number1754
Policy instance 1
Insurance contract or identification number1754
Number of Individuals Covered179
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $20,714
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,327,139
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $20,714
Amount paid for insurance broker fees0
Insurance broker organization code?3
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number30039791
Policy instance 4
Insurance contract or identification number30039791
Number of Individuals Covered210
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $1,533
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $35,333
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,533
Amount paid for insurance broker fees0
Insurance broker organization code?3
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract numberKM05944742
Policy instance 3
Insurance contract or identification numberKM05944742
Number of Individuals Covered917
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $4,899
Total amount of fees paid to insurance companyUSD $2,482
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $183,824
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,899
Amount paid for insurance broker fees71
Additional information about fees paid to insurance brokerNON-MONETARY COMPENSATION
Insurance broker organization code?3
EMPATHIA, INC. (National Association of Insurance Commissioners NAIC id number: 62419 )
Policy contract number000
Policy instance 5
Insurance contract or identification number000
Number of Individuals Covered300
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
Other welfare benefits providedEMPLOYEE ASSISTANCE PROGRAM
Welfare Benefit Premiums Paid to CarrierUSD $6,588
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 numberGL162916
Policy instance 6
Insurance contract or identification numberGL162916
Number of Individuals Covered293
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $11,952
Total amount of fees paid to insurance companyUSD $8,321
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $222,649
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $11,952
Amount paid for insurance broker fees0
Insurance broker organization code?3
Additional information about fees paid to insurance brokerADMINISTRATIVE AND OTHER FEES
BLUE CROSS BLUE SHIELD OF WISCONSIN (National Association of Insurance Commissioners NAIC id number: 54003 )
Policy contract numberW12267
Policy instance 2
Insurance contract or identification numberW12267
Number of Individuals Covered362
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $20,317
Total amount of fees paid to insurance companyUSD $4,068
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $2,753,269
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $20,317
Amount paid for insurance broker fees4068
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLUG0ASLP
Policy instance 6
Insurance contract or identification numberGLUG0ASLP
Number of Individuals Covered299
Insurance policy start date2020-01-01
Insurance policy end date2020-11-30
Total amount of commissions paid to insurance brokerUSD $16,308
Total amount of fees paid to insurance companyUSD $6,534
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $202,017
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $16,308
Amount paid for insurance broker fees6534
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract numberGL162916
Policy instance 5
Insurance contract or identification numberGL162916
Number of Individuals Covered293
Insurance policy start date2020-12-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number30039791
Policy instance 4
Insurance contract or identification number30039791
Number of Individuals Covered208
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $1,588
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $33,360
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,588
Amount paid for insurance broker fees0
Insurance broker organization code?3
DEAN HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 96156 )
Policy contract number1754
Policy instance 1
Insurance contract or identification number1754
Number of Individuals Covered228
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $18,672
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,486,017
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $18,672
Amount paid for insurance broker fees0
Insurance broker organization code?3
BLUE CROSS BLUE SHIELD OF WISCONSIN (National Association of Insurance Commissioners NAIC id number: 54003 )
Policy contract numberW12267
Policy instance 2
Insurance contract or identification numberW12267
Number of Individuals Covered362
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $17,644
Total amount of fees paid to insurance companyUSD $6,300
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $2,553,507
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $17,644
Amount paid for insurance broker fees6300
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract numberKM05944742
Policy instance 3
Insurance contract or identification numberKM05944742
Number of Individuals Covered538
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $5,343
Total amount of fees paid to insurance companyUSD $3,256
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $208,859
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,343
Amount paid for insurance broker fees52
Additional information about fees paid to insurance brokerNON-MONETARY COMPENSATION
Insurance broker organization code?3
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number5944742
Policy instance 3
Insurance contract or identification number5944742
Number of Individuals Covered636
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $6,020
Total amount of fees paid to insurance companyUSD $3,473
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $229,732
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6,020
Amount paid for insurance broker fees73
Additional information about fees paid to insurance brokerNON-MONETARY COMPENSATION
Insurance broker organization code?3
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number902247
Policy instance 2
Insurance contract or identification number902247
Number of Individuals Covered408
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 $23,364
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $3,120,904
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $0
Amount paid for insurance broker fees23364
Additional information about fees paid to insurance brokerSERVICE FEE AGREEMENT
Insurance broker organization code?3
DEAN HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 96156 )
Policy contract number1754
Policy instance 1
Insurance contract or identification number1754
Number of Individuals Covered233
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $17,224
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,491,943
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $17,224
Amount paid for insurance broker fees0
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLUG0ASLP
Policy instance 5
Insurance contract or identification numberGLUG0ASLP
Number of Individuals Covered332
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $19,632
Total amount of fees paid to insurance companyUSD $9,881
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $255,589
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $19,632
Amount paid for insurance broker fees9881
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number30039791
Policy instance 4
Insurance contract or identification number30039791
Number of Individuals Covered223
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $1,897
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $34,348
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,897
Amount paid for insurance broker fees0
Insurance broker organization code?3
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number902247
Policy instance 2
Insurance contract or identification number902247
Number of Individuals Covered411
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 $25,553
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $3,116,161
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $0
Amount paid for insurance broker fees25553
Additional information about fees paid to insurance brokerSERVICE FEE AGREEMENT
Insurance broker organization code?3
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number5944742
Policy instance 3
Insurance contract or identification number5944742
Number of Individuals Covered647
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $5,320
Total amount of fees paid to insurance companyUSD $4,739
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $228,556
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,320
Amount paid for insurance broker fees95
Additional information about fees paid to insurance brokerNON-MONETARY COMPENSATION
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLUG0ASLP
Policy instance 5
Insurance contract or identification numberGLUG0ASLP
Number of Individuals Covered326
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $21,762
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $282,303
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $21,762
Amount paid for insurance broker fees0
Insurance broker organization code?3
DEAN HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 96156 )
Policy contract number1754
Policy instance 1
Insurance contract or identification number1754
Number of Individuals Covered258
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $20,744
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,462,960
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $20,744
Amount paid for insurance broker fees0
Insurance broker organization code?3
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number30039791
Policy instance 4
Insurance contract or identification number30039791
Number of Individuals Covered211
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $1,546
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $34,215
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,546
Amount paid for insurance broker fees0
Insurance broker organization code?3
DEAN HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 96156 )
Policy contract number1754
Policy instance 1
Insurance contract or identification number1754
Number of Individuals Covered266
Insurance policy start date2016-06-01
Insurance policy end date2017-05-31
Total amount of commissions paid to insurance brokerUSD $19,530
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,458,672
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $19,530
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameLOCKTON COMPANIES, LLC
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLUG0ASLP
Policy instance 10
Insurance contract or identification numberGLUG0ASLP
Number of Individuals Covered302
Insurance policy start date2016-06-01
Insurance policy end date2017-05-31
Total amount of commissions paid to insurance brokerUSD $22,148
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $282,040
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $22,148
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameLOCKTON COMPANIES, LLC
HUMANA (National Association of Insurance Commissioners NAIC id number: 70580 )
Policy contract number686758
Policy instance 5
Insurance contract or identification number686758
Number of Individuals Covered261
Insurance policy start date2016-06-01
Insurance policy end date2017-05-31
Total amount of commissions paid to insurance brokerUSD $5,653
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $226,495
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,653
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameLOCKTON COMPANIES, LLC
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract numberKM05944742
Policy instance 6
Insurance contract or identification numberKM05944742
Number of Individuals Covered559
Insurance policy start date2017-06-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $3,520
Total amount of fees paid to insurance companyUSD $2,174
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $123,003
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,520
Amount paid for insurance broker fees57
Additional information about fees paid to insurance brokerNON-MONETARY COMPENSATION
Insurance broker organization code?3
Insurance broker nameLOCKTON COMPANIES, LLC
DEAN HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 96156 )
Policy contract number1754
Policy instance 2
Insurance contract or identification number1754
Number of Individuals Covered264
Insurance policy start date2017-06-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $9,630
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $852,569
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $9,630
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameLOCKTON COMPANIES, LLC
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number902247
Policy instance 3
Insurance contract or identification number902247
Number of Individuals Covered349
Insurance policy start date2016-06-01
Insurance policy end date2017-05-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $24,137
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $2,342,671
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $0
Amount paid for insurance broker fees24137
Additional information about fees paid to insurance brokerSERVICE FEE AGREEMENT BONUS
Insurance broker organization code?3
Insurance broker nameLOCKTON COMPANIES, LLC
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number902247
Policy instance 4
Insurance contract or identification number902247
Number of Individuals Covered161
Insurance policy start date2017-06-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $10,098
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,425,911
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $0
Amount paid for insurance broker fees10098
Additional information about fees paid to insurance brokerSERVICE FEE AGREEMENT
Insurance broker organization code?3
Insurance broker nameLOCKTON COMPANIES, LLC
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number30039791
Policy instance 8
Insurance contract or identification number30039791
Number of Individuals Covered172
Insurance policy start date2017-05-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $1,020
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $17,596
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,020
Amount paid for insurance broker fees0
Insurance broker nameLOCKTON COMPANIES, LLC
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLUG0ASLP
Policy instance 9
Insurance contract or identification numberGLUG0ASLP
Number of Individuals Covered316
Insurance policy start date2017-06-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $17,277
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $167,547
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $17,277
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameLOCKTON COMPANIES, LLC
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number30039791
Policy instance 7
Insurance contract or identification number30039791
Number of Individuals Covered153
Insurance policy start date2016-05-01
Insurance policy end date2017-04-30
Total amount of commissions paid to insurance brokerUSD $1,229
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $24,094
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,229
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameLOCKTON COMPANIES, LLC
DEAN HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 96156 )
Policy contract number1754
Policy instance 1
Insurance contract or identification number1754
Number of Individuals Covered317
Insurance policy start date2014-06-01
Insurance policy end date2015-05-31
Total amount of commissions paid to insurance brokerUSD $20,652
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,455,857
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $20,652
Insurance broker organization code?3
Insurance broker nameLOCKTON COMPANIES, LLC
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLTD0ASLP
Policy instance 7
Insurance contract or identification numberGLTD0ASLP
Number of Individuals Covered278
Insurance policy start date2014-06-01
Insurance policy end date2015-05-31
Total amount of commissions paid to insurance brokerUSD $4,572
Total amount of fees paid to insurance companyUSD $1,162
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $57,219
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,572
Amount paid for insurance broker fees1162
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
Insurance broker nameLOCKTON COMPANIES, LLC
HUMANA (National Association of Insurance Commissioners NAIC id number: 70580 )
Policy contract number686758
Policy instance 2
Insurance contract or identification number686758
Number of Individuals Covered242
Insurance policy start date2015-01-01
Insurance policy end date2015-05-31
Total amount of commissions paid to insurance brokerUSD $3,337
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $109,284
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,337
Insurance broker organization code?3
Insurance broker nameLOCKTON COMPANIES, LLC
PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 )
Policy contract number5-07612
Policy instance 3
Insurance contract or identification number5-07612
Number of Individuals Covered15
Insurance policy start date2014-06-01
Insurance policy end date2015-05-31
Total amount of commissions paid to insurance brokerUSD $1,057
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $2,950
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $461
Insurance broker organization code?3
Insurance broker nameSECURA CONSULTANTS
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number30039791
Policy instance 4
Insurance contract or identification number30039791
Number of Individuals Covered97
Insurance policy start date2014-05-01
Insurance policy end date2015-04-30
Total amount of commissions paid to insurance brokerUSD $986
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $16,634
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $986
Insurance broker organization code?3
Insurance broker nameLOCKTON COMPANIES, LLC
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGVTL0ASLP
Policy instance 5
Insurance contract or identification numberGVTL0ASLP
Number of Individuals Covered88
Insurance policy start date2014-06-01
Insurance policy end date2015-05-31
Total amount of commissions paid to insurance brokerUSD $9,383
Total amount of fees paid to insurance companyUSD $2,417
Other welfare benefits providedVOLUNTARY: LIFE AND AD&D
Welfare Benefit Premiums Paid to CarrierUSD $102,069
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $9,383
Amount paid for insurance broker fees2417
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
Insurance broker nameLOCKTON COMPANIES, LLC
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLUG0ASLP
Policy instance 6
Insurance contract or identification numberGLUG0ASLP
Number of Individuals Covered279
Insurance policy start date2014-06-01
Insurance policy end date2015-05-31
Total amount of commissions paid to insurance brokerUSD $3,784
Total amount of fees paid to insurance companyUSD $985
Life Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $45,687
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,784
Amount paid for insurance broker fees985
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
Insurance broker nameLOCKTON COMPANIES, LLC
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGUG 0ASLP
Policy instance 8
Insurance contract or identification numberGUG 0ASLP
Number of Individuals Covered279
Insurance policy start date2014-06-01
Insurance policy end date2015-05-31
Total amount of commissions paid to insurance brokerUSD $4,627
Total amount of fees paid to insurance companyUSD $1,594
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $75,089
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,627
Amount paid for insurance broker fees1594
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
Insurance broker nameLOCKTON COMPANIES, LLC
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number902247
Policy instance 9
Insurance contract or identification number902247
Number of Individuals Covered261
Insurance policy start date2014-06-01
Insurance policy end date2015-05-31
Total amount of fees paid to insurance companyUSD $16,016
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,703,106
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Amount paid for insurance broker fees16016
Additional information about fees paid to insurance brokerSERVICE FEE AGREEMENT
Insurance broker organization code?3
Insurance broker nameLOCKTON COMPANIES, LLC
CONNECTICARE, INC. (National Association of Insurance Commissioners NAIC id number: 95675 )
Policy contract number344
Policy instance 1
Insurance contract or identification number344
Number of Individuals Covered63
Insurance policy start date2013-06-01
Insurance policy end date2014-05-31
Total amount of commissions paid to insurance brokerUSD $15,149
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $362,064
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $8,031
Insurance broker organization code?3
Insurance broker nameLOCKTON COMPANIES, LLC
DEAN HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 96156 )
Policy contract number1754
Policy instance 2
Insurance contract or identification number1754
Number of Individuals Covered470
Insurance policy start date2013-06-01
Insurance policy end date2014-05-31
Total amount of commissions paid to insurance brokerUSD $25,515
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $2,563,595
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $14,822
Insurance broker organization code?3
Insurance broker nameLOCKTON COMPANIES, LLC
HUMANA (National Association of Insurance Commissioners NAIC id number: 70580 )
Policy contract number686758
Policy instance 3
Insurance contract or identification number686758
Number of Individuals Covered248
Insurance policy start date2014-01-01
Insurance policy end date2014-12-31
Total amount of commissions paid to insurance brokerUSD $5,782
Total amount of fees paid to insurance companyUSD $3,217
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $231,930
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $415
Amount paid for insurance broker fees3217
Additional information about fees paid to insurance brokerVOLUME INCENTIVES
Insurance broker organization code?3
Insurance broker nameLOCKTON COMPANIES, LLC
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number72284
Policy instance 4
Insurance contract or identification number72284
Number of Individuals Covered25
Insurance policy start date2013-06-01
Insurance policy end date2014-05-31
Total amount of commissions paid to insurance brokerUSD $4,787
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $102,179
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,022
Insurance broker organization code?3
Insurance broker nameM3 INSURANCE SOLUTIONS, INC.
PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 )
Policy contract number1035616
Policy instance 5
Insurance contract or identification number1035616
Number of Individuals Covered280
Insurance policy start date2013-07-01
Insurance policy end date2014-05-31
Total amount of commissions paid to insurance brokerUSD $7,028
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $99,216
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,922
Insurance broker organization code?3
Insurance broker nameM3 INSURANCE SOLUTIONS, INC.
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 54682 )
Policy contract number30039791
Policy instance 7
Insurance contract or identification number30039791
Number of Individuals Covered79
Insurance policy start date2013-05-01
Insurance policy end date2014-04-30
Total amount of commissions paid to insurance brokerUSD $852
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $12,866
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $660
Insurance broker organization code?3
Insurance broker nameLOCKTON COMPANIES, LLC
UNICARE HEALTH AND LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80314 )
Policy contract number130808
Policy instance 6
Insurance contract or identification number130808
Number of Individuals Covered209
Insurance policy start date2014-03-01
Insurance policy end date2014-05-31
Life Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $25,056
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
DEAN HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 96156 )
Policy contract number1754
Policy instance 2
Insurance contract or identification number1754
Number of Individuals Covered435
Insurance policy start date2012-06-01
Insurance policy end date2013-05-31
Total amount of commissions paid to insurance brokerUSD $24,645
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 BenefitYes
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 $2,021,608
Commission paid to Insurance BrokerUSD $24,645
Insurance broker organization code?3
Insurance broker nameKEVIN CLOUGHERTY
UNICARE HEALTH AND LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80314 )
Policy contract number130808
Policy instance 3
Insurance contract or identification number130808
Number of Individuals Covered208
Insurance policy start date2013-03-01
Insurance policy end date2014-02-28
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 BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedADD
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 $148,935
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number72284
Policy instance 1
Insurance contract or identification number72284
Number of Individuals Covered24
Insurance policy start date2012-06-01
Insurance policy end date2013-05-31
Total amount of commissions paid to insurance brokerUSD $4,538
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 BenefitYes
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 $95,595
Commission paid to Insurance BrokerUSD $4,538
Insurance broker organization code?3
Insurance broker nameM3 INSURANCE SOLUTIONS, INC
CONNECTICARE, INC. (National Association of Insurance Commissioners NAIC id number: 95675 )
Policy contract number344
Policy instance 4
Insurance contract or identification number344
Number of Individuals Covered34
Insurance policy start date2012-06-01
Insurance policy end date2013-05-31
Total amount of commissions paid to insurance brokerUSD $10,032
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 BenefitYes
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 $225,791
Commission paid to Insurance BrokerUSD $10,032
Insurance broker organization code?3
Insurance broker nameMORTENSON MATZELLE & MELDRUM INC
HUMANA (National Association of Insurance Commissioners NAIC id number: 70580 )
Policy contract number686758
Policy instance 5
Insurance contract or identification number686758
Number of Individuals Covered226
Insurance policy start date2013-01-01
Insurance policy end date2013-12-31
Total amount of commissions paid to insurance brokerUSD $6,048
Total amount of fees paid to insurance companyUSD $4,207
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 BenefitYes
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 $205,433
Commission paid to Insurance BrokerUSD $6,048
Amount paid for insurance broker fees4207
Additional information about fees paid to insurance brokerVOLUME INCENTIVES
Insurance broker organization code?3
Insurance broker nameMORTENSON MATZELLE AND MELDRUM INC
PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 )
Policy contract number1035616
Policy instance 6
Insurance contract or identification number1035616
Number of Individuals Covered263
Insurance policy start date2013-03-01
Insurance policy end date2013-06-30
Total amount of commissions paid to insurance brokerUSD $3,370
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 BenefitYes
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 $27,173
Commission paid to Insurance BrokerUSD $3,370
Insurance broker organization code?3
Insurance broker nameM3 INS SOLUTIONS INC
CONNECTICARE, INC. (National Association of Insurance Commissioners NAIC id number: 95675 )
Policy contract number1799
Policy instance 4
Insurance contract or identification number1799
Number of Individuals Covered30
Insurance policy start date2011-06-01
Insurance policy end date2012-05-31
Total amount of commissions paid to insurance brokerUSD $8,413
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 BenefitYes
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 $186,953
Commission paid to Insurance BrokerUSD $8,413
Insurance broker organization code?3
Insurance broker nameMORTENSON MATZELLE & MELDRUM INC
HUMANA (National Association of Insurance Commissioners NAIC id number: 70580 )
Policy contract number686758
Policy instance 6
Insurance contract or identification number686758
Number of Individuals Covered218
Insurance policy start date2012-01-01
Insurance policy end date2012-12-31
Total amount of commissions paid to insurance brokerUSD $12,665
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $181,938
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?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
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 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
Commission paid to Insurance BrokerUSD $12,665
Insurance broker organization code?3
Insurance broker nameMORTENSON MATZELLE AND MELDRUM INC
CONNECTICARE, INC. (National Association of Insurance Commissioners NAIC id number: 95675 )
Policy contract number001799
Policy instance 4
Insurance contract or identification number001799
Number of Individuals Covered30
Insurance policy start date2011-06-01
Insurance policy end date2012-05-31
Total amount of commissions paid to insurance brokerUSD $8,413
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $186,953
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
UNICARE HEALTH AND LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80314 )
Policy contract number130808
Policy instance 3
Insurance contract or identification number130808
Number of Individuals Covered192
Insurance policy start date2012-03-01
Insurance policy end date2013-02-28
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Life Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $128,953
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?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
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
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
DEAN HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 96156 )
Policy contract number17540-17545
Policy instance 2
Insurance contract or identification number17540-17545
Number of Individuals Covered420
Insurance policy start date2011-06-01
Insurance policy end date2012-05-31
Total amount of commissions paid to insurance brokerUSD $23,337
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,801,437
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?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
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
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
Commission paid to Insurance BrokerUSD $23,337
Insurance broker organization code?3
Insurance broker nameM3 INSURANCE SOLUTIONS INC
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number72284
Policy instance 1
Insurance contract or identification number72284
Number of Individuals Covered21
Insurance policy start date2011-06-01
Insurance policy end date2012-05-31
Total amount of commissions paid to insurance brokerUSD $5,321
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $79,142
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?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
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
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
Commission paid to Insurance BrokerUSD $5,321
Insurance broker organization code?3
Insurance broker nameM3 INSURANCE SOLUTIONS, INC
PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 )
Policy contract numberH36903
Policy instance 7
Insurance contract or identification numberH36903
Number of Individuals Covered256
Insurance policy start date2012-07-01
Insurance policy end date2013-02-28
Total amount of commissions paid to insurance brokerUSD $4,895
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 BenefitYes
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 $48,526
Commission paid to Insurance BrokerUSD $4,895
Insurance broker organization code?3
Insurance broker nameM3 INS SOLUTIONS INC
PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 )
Policy contract numberH36903
Policy instance 5
Insurance contract or identification numberH36903
Number of Individuals Covered240
Insurance policy start date2011-07-01
Insurance policy end date2012-06-30
Total amount of commissions paid to insurance brokerUSD $6,502
Total amount of fees paid to insurance companyUSD $1,340
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Health Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $82,973
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?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
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
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life 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
Commission paid to Insurance BrokerUSD $6,502
Amount paid for insurance broker fees1340
Additional information about fees paid to insurance brokerSERVICE FEE, BONUS
Insurance broker organization code?3
Insurance broker nameM3 INSURANCE SOLUTIONS, INC
HUMANA (National Association of Insurance Commissioners NAIC id number: 70580 )
Policy contract number686758
Policy instance 6
Insurance contract or identification number686758
Number of Individuals Covered198
Insurance policy start date2011-01-01
Insurance policy end date2011-12-31
Total amount of commissions paid to insurance brokerUSD $11,543
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $175,377
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 )
Policy contract numberH36903
Policy instance 5
Insurance contract or identification numberH36903
Number of Individuals Covered223
Insurance policy start date2010-07-01
Insurance policy end date2011-06-30
Total amount of commissions paid to insurance brokerUSD $7,183
Total amount of fees paid to insurance companyUSD $23,747
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Health Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $548,873
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
CONNECTICARE, INC. (National Association of Insurance Commissioners NAIC id number: 95675 )
Policy contract number001799
Policy instance 4
Insurance contract or identification number001799
Number of Individuals Covered32
Insurance policy start date2010-06-01
Insurance policy end date2011-05-31
Total amount of commissions paid to insurance brokerUSD $8,077
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $179,483
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
UNICARE HEALTH AND LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80314 )
Policy contract number130808
Policy instance 3
Insurance contract or identification number130808
Number of Individuals Covered164
Insurance policy start date2011-03-01
Insurance policy end date2012-02-28
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Life Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $113,200
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
DEAN HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 96156 )
Policy contract number17540-17545
Policy instance 2
Insurance contract or identification number17540-17545
Number of Individuals Covered325
Insurance policy start date2010-06-01
Insurance policy end date2011-05-31
Total amount of commissions paid to insurance brokerUSD $21,091
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,175,935
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number72284
Policy instance 1
Insurance contract or identification number72284
Number of Individuals Covered25
Insurance policy start date2010-06-01
Insurance policy end date2011-05-31
Total amount of commissions paid to insurance brokerUSD $4,719
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $75,580
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
HUMANA (National Association of Insurance Commissioners NAIC id number: 70580 )
Policy contract number686758
Policy instance 6
Insurance contract or identification number686758
Number of Individuals Covered185
Insurance policy start date2010-01-01
Insurance policy end date2010-12-31
Total amount of commissions paid to insurance brokerUSD $10,844
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $194,150
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $10,844
Insurance broker nameMORTENSON MATZELLE AND MELDRUM INC
PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 )
Policy contract numberH36903
Policy instance 5
Insurance contract or identification numberH36903
Number of Individuals Covered228
Insurance policy start date2009-07-01
Insurance policy end date2010-06-30
Total amount of commissions paid to insurance brokerUSD $7,168
Total amount of fees paid to insurance companyUSD $26,123
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Health Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $525,065
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $7,168
Amount paid for insurance broker fees26123
Additional information about fees paid to insurance brokerSERVICE FEE, BONUS
Insurance broker organization code?3
Insurance broker nameM3 INSURANCE SOLUTIONS, INC.
CONNECTICARE, INC. (National Association of Insurance Commissioners NAIC id number: 95675 )
Policy contract number001799
Policy instance 4
Insurance contract or identification number001799
Number of Individuals Covered31
Insurance policy start date2009-06-01
Insurance policy end date2010-05-31
Total amount of commissions paid to insurance brokerUSD $6,425
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $142,767
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6,425
Insurance broker nameMORTENSON MATZELLE & MELDRUM INC
UNICARE HEALTH AND LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80314 )
Policy contract number130808
Policy instance 3
Insurance contract or identification number130808
Number of Individuals Covered163
Insurance policy start date2010-03-01
Insurance policy end date2011-02-28
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Life Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $115,751
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
DEAN HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 96156 )
Policy contract number17540-17545
Policy instance 2
Insurance contract or identification number17540-17545
Number of Individuals Covered332
Insurance policy start date2009-06-01
Insurance policy end date2010-05-31
Total amount of commissions paid to insurance brokerUSD $23,287
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,413,740
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $23,287
Insurance broker nameM3 INSURANCE SOLUTIONS, INC.
KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number72284
Policy instance 1
Insurance contract or identification number72284
Number of Individuals Covered24
Insurance policy start date2009-06-01
Insurance policy end date2010-05-31
Total amount of commissions paid to insurance brokerUSD $4,830
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $81,694
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,830
Insurance broker nameJAMES KROGSTAD

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