CAP SERVICES, INC. has sponsored the creation of one or more 401k plans.
Additional information about CAP SERVICES, INC.
Submission information for form 5500 for 401k plan CAP SERVICES, INC. SECTION 125 PLAN
401k plan membership statisitcs for CAP SERVICES, INC. SECTION 125 PLAN
| Measure | Date | Value |
|---|
| 2022: CAP SERVICES, INC. SECTION 125 PLAN 2022 401k membership |
|---|
| Total participants, beginning-of-year | 2022-12-16 | 108 |
| Total number of active participants reported on line 7a of the Form 5500 | 2022-12-16 | 114 |
| Number of retired or separated participants receiving benefits | 2022-12-16 | 2 |
| Number of other retired or separated participants entitled to future benefits | 2022-12-16 | 0 |
| Total of all active and inactive participants | 2022-12-16 | 116 |
| 2021: CAP SERVICES, INC. SECTION 125 PLAN 2021 401k membership |
|---|
| Total participants, beginning-of-year | 2021-12-16 | 190 |
| Total number of active participants reported on line 7a of the Form 5500 | 2021-12-16 | 186 |
| Number of retired or separated participants receiving benefits | 2021-12-16 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2021-12-16 | 0 |
| Total of all active and inactive participants | 2021-12-16 | 186 |
| 2020: CAP SERVICES, INC. SECTION 125 PLAN 2020 401k membership |
|---|
| Total participants, beginning-of-year | 2020-12-16 | 199 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-12-16 | 190 |
| Number of retired or separated participants receiving benefits | 2020-12-16 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2020-12-16 | 0 |
| Total of all active and inactive participants | 2020-12-16 | 190 |
| 2019: CAP SERVICES, INC. SECTION 125 PLAN 2019 401k membership |
|---|
| Total participants, beginning-of-year | 2019-12-16 | 232 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-12-16 | 235 |
| Number of retired or separated participants receiving benefits | 2019-12-16 | 2 |
| Number of other retired or separated participants entitled to future benefits | 2019-12-16 | 0 |
| Total of all active and inactive participants | 2019-12-16 | 237 |
| 2018: CAP SERVICES, INC. SECTION 125 PLAN 2018 401k membership |
|---|
| Total participants, beginning-of-year | 2018-12-16 | 186 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-12-16 | 205 |
| Number of retired or separated participants receiving benefits | 2018-12-16 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2018-12-16 | 0 |
| Total of all active and inactive participants | 2018-12-16 | 205 |
| 2017: CAP SERVICES, INC. SECTION 125 PLAN 2017 401k membership |
|---|
| Total participants, beginning-of-year | 2017-12-16 | 199 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-12-16 | 186 |
| Number of retired or separated participants receiving benefits | 2017-12-16 | 5 |
| Number of other retired or separated participants entitled to future benefits | 2017-12-16 | 0 |
| Total of all active and inactive participants | 2017-12-16 | 191 |
| 2016: CAP SERVICES, INC. SECTION 125 PLAN 2016 401k membership |
|---|
| Total participants, beginning-of-year | 2016-12-16 | 121 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-12-16 | 105 |
| Number of retired or separated participants receiving benefits | 2016-12-16 | 2 |
| Number of other retired or separated participants entitled to future benefits | 2016-12-16 | 0 |
| Total of all active and inactive participants | 2016-12-16 | 107 |
| 2015: CAP SERVICES, INC. SECTION 125 PLAN 2015 401k membership |
|---|
| Total participants, beginning-of-year | 2015-12-16 | 193 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-12-16 | 190 |
| Number of retired or separated participants receiving benefits | 2015-12-16 | 2 |
| Number of other retired or separated participants entitled to future benefits | 2015-12-16 | 0 |
| Total of all active and inactive participants | 2015-12-16 | 192 |
| 2014: CAP SERVICES, INC. SECTION 125 PLAN 2014 401k membership |
|---|
| Total participants, beginning-of-year | 2014-12-16 | 189 |
| Total number of active participants reported on line 7a of the Form 5500 | 2014-12-16 | 193 |
| Number of retired or separated participants receiving benefits | 2014-12-16 | 2 |
| Number of other retired or separated participants entitled to future benefits | 2014-12-16 | 0 |
| Total of all active and inactive participants | 2014-12-16 | 195 |
| 2013: CAP SERVICES, INC. SECTION 125 PLAN 2013 401k membership |
|---|
| Total participants, beginning-of-year | 2013-12-16 | 193 |
| Total number of active participants reported on line 7a of the Form 5500 | 2013-12-16 | 189 |
| Number of retired or separated participants receiving benefits | 2013-12-16 | 3 |
| Number of other retired or separated participants entitled to future benefits | 2013-12-16 | 0 |
| Total of all active and inactive participants | 2013-12-16 | 192 |
| 2012: CAP SERVICES, INC. SECTION 125 PLAN 2012 401k membership |
|---|
| Total participants, beginning-of-year | 2012-12-16 | 187 |
| Total number of active participants reported on line 7a of the Form 5500 | 2012-12-16 | 187 |
| Number of retired or separated participants receiving benefits | 2012-12-16 | 6 |
| Number of other retired or separated participants entitled to future benefits | 2012-12-16 | 0 |
| Total of all active and inactive participants | 2012-12-16 | 193 |
| 2011: CAP SERVICES, INC. SECTION 125 PLAN 2011 401k membership |
|---|
| Total participants, beginning-of-year | 2011-12-16 | 193 |
| Total number of active participants reported on line 7a of the Form 5500 | 2011-12-16 | 187 |
| Number of retired or separated participants receiving benefits | 2011-12-16 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2011-12-16 | 13 |
| Total of all active and inactive participants | 2011-12-16 | 200 |
| 2010: CAP SERVICES, INC. SECTION 125 PLAN 2010 401k membership |
|---|
| Total participants, beginning-of-year | 2010-12-16 | 206 |
| Total number of active participants reported on line 7a of the Form 5500 | 2010-12-16 | 195 |
| Number of retired or separated participants receiving benefits | 2010-12-16 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2010-12-16 | 9 |
| Total of all active and inactive participants | 2010-12-16 | 204 |
| 2009: CAP SERVICES, INC. SECTION 125 PLAN 2009 401k membership |
|---|
| Total participants, beginning-of-year | 2009-12-16 | 181 |
| Total number of active participants reported on line 7a of the Form 5500 | 2009-12-16 | 144 |
| Number of retired or separated participants receiving benefits | 2009-12-16 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2009-12-16 | 0 |
| Total of all active and inactive participants | 2009-12-16 | 144 |
| Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits | 2009-12-16 | 0 |
| 2008: CAP SERVICES, INC. SECTION 125 PLAN 2008 401k membership |
|---|
| Total participants, beginning-of-year | 2008-12-16 | 173 |
| Total number of active participants reported on line 7a of the Form 5500 | 2008-12-16 | 181 |
| Number of retired or separated participants receiving benefits | 2008-12-16 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2008-12-16 | 0 |
| Total of all active and inactive participants | 2008-12-16 | 181 |
| 2022: CAP SERVICES, INC. SECTION 125 PLAN 2022 form 5500 responses |
|---|
| 2022-12-16 | Type of plan entity | Single employer plan |
| 2022-12-16 | Submission has been amended | No |
| 2022-12-16 | This submission is the final filing | No |
| 2022-12-16 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2022-12-16 | Plan is a collectively bargained plan | No |
| 2022-12-16 | Plan funding arrangement – Insurance | Yes |
| 2022-12-16 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2022-12-16 | Plan benefit arrangement – Insurance | Yes |
| 2022-12-16 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2021: CAP SERVICES, INC. SECTION 125 PLAN 2021 form 5500 responses |
|---|
| 2021-12-16 | Type of plan entity | Single employer plan |
| 2021-12-16 | Submission has been amended | No |
| 2021-12-16 | This submission is the final filing | No |
| 2021-12-16 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2021-12-16 | Plan is a collectively bargained plan | No |
| 2021-12-16 | Plan funding arrangement – Insurance | Yes |
| 2021-12-16 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2021-12-16 | Plan benefit arrangement – Insurance | Yes |
| 2021-12-16 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2020: CAP SERVICES, INC. SECTION 125 PLAN 2020 form 5500 responses |
|---|
| 2020-12-16 | Type of plan entity | Single employer plan |
| 2020-12-16 | Submission has been amended | No |
| 2020-12-16 | This submission is the final filing | No |
| 2020-12-16 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2020-12-16 | Plan is a collectively bargained plan | No |
| 2020-12-16 | Plan funding arrangement – Insurance | Yes |
| 2020-12-16 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2020-12-16 | Plan benefit arrangement – Insurance | Yes |
| 2020-12-16 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2019: CAP SERVICES, INC. SECTION 125 PLAN 2019 form 5500 responses |
|---|
| 2019-12-16 | Type of plan entity | Single employer plan |
| 2019-12-16 | Submission has been amended | No |
| 2019-12-16 | This submission is the final filing | No |
| 2019-12-16 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2019-12-16 | Plan is a collectively bargained plan | No |
| 2019-12-16 | Plan funding arrangement – Insurance | Yes |
| 2019-12-16 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2019-12-16 | Plan benefit arrangement – Insurance | Yes |
| 2019-12-16 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2018: CAP SERVICES, INC. SECTION 125 PLAN 2018 form 5500 responses |
|---|
| 2018-12-16 | Type of plan entity | Single employer plan |
| 2018-12-16 | Submission has been amended | No |
| 2018-12-16 | This submission is the final filing | No |
| 2018-12-16 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2018-12-16 | Plan is a collectively bargained plan | No |
| 2018-12-16 | Plan funding arrangement – Insurance | Yes |
| 2018-12-16 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2018-12-16 | Plan benefit arrangement – Insurance | Yes |
| 2018-12-16 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2017: CAP SERVICES, INC. SECTION 125 PLAN 2017 form 5500 responses |
|---|
| 2017-12-16 | Type of plan entity | Single employer plan |
| 2017-12-16 | Submission has been amended | No |
| 2017-12-16 | This submission is the final filing | No |
| 2017-12-16 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2017-12-16 | Plan is a collectively bargained plan | No |
| 2017-12-16 | Plan funding arrangement – Insurance | Yes |
| 2017-12-16 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2017-12-16 | Plan benefit arrangement – Insurance | Yes |
| 2017-12-16 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2016: CAP SERVICES, INC. SECTION 125 PLAN 2016 form 5500 responses |
|---|
| 2016-12-16 | Type of plan entity | Single employer plan |
| 2016-12-16 | Submission has been amended | No |
| 2016-12-16 | This submission is the final filing | No |
| 2016-12-16 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2016-12-16 | Plan is a collectively bargained plan | No |
| 2016-12-16 | Plan funding arrangement – Insurance | Yes |
| 2016-12-16 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2016-12-16 | Plan benefit arrangement – Insurance | Yes |
| 2016-12-16 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2015: CAP SERVICES, INC. SECTION 125 PLAN 2015 form 5500 responses |
|---|
| 2015-12-16 | Type of plan entity | Single employer plan |
| 2015-12-16 | Submission has been amended | No |
| 2015-12-16 | This submission is the final filing | No |
| 2015-12-16 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2015-12-16 | Plan is a collectively bargained plan | No |
| 2015-12-16 | Plan funding arrangement – Insurance | Yes |
| 2015-12-16 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2015-12-16 | Plan benefit arrangement – Insurance | Yes |
| 2015-12-16 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2014: CAP SERVICES, INC. SECTION 125 PLAN 2014 form 5500 responses |
|---|
| 2014-12-16 | Type of plan entity | Single employer plan |
| 2014-12-16 | Submission has been amended | No |
| 2014-12-16 | This submission is the final filing | No |
| 2014-12-16 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2014-12-16 | Plan is a collectively bargained plan | No |
| 2014-12-16 | Plan funding arrangement – Insurance | Yes |
| 2014-12-16 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2014-12-16 | Plan benefit arrangement – Insurance | Yes |
| 2014-12-16 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2013: CAP SERVICES, INC. SECTION 125 PLAN 2013 form 5500 responses |
|---|
| 2013-12-16 | Type of plan entity | Single employer plan |
| 2013-12-16 | Submission has been amended | No |
| 2013-12-16 | This submission is the final filing | No |
| 2013-12-16 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2013-12-16 | Plan is a collectively bargained plan | No |
| 2013-12-16 | Plan funding arrangement – Insurance | Yes |
| 2013-12-16 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2013-12-16 | Plan benefit arrangement – Insurance | Yes |
| 2013-12-16 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2012: CAP SERVICES, INC. SECTION 125 PLAN 2012 form 5500 responses |
|---|
| 2012-12-16 | Type of plan entity | Single employer plan |
| 2012-12-16 | Submission has been amended | No |
| 2012-12-16 | This submission is the final filing | No |
| 2012-12-16 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2012-12-16 | Plan is a collectively bargained plan | No |
| 2012-12-16 | Plan funding arrangement – Insurance | Yes |
| 2012-12-16 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2012-12-16 | Plan benefit arrangement – Insurance | Yes |
| 2012-12-16 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2011: CAP SERVICES, INC. SECTION 125 PLAN 2011 form 5500 responses |
|---|
| 2011-12-16 | Type of plan entity | Single employer plan |
| 2011-12-16 | Submission has been amended | No |
| 2011-12-16 | This submission is the final filing | No |
| 2011-12-16 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2011-12-16 | Plan is a collectively bargained plan | No |
| 2011-12-16 | Plan funding arrangement – Insurance | Yes |
| 2011-12-16 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2011-12-16 | Plan benefit arrangement – Insurance | Yes |
| 2011-12-16 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2010: CAP SERVICES, INC. SECTION 125 PLAN 2010 form 5500 responses |
|---|
| 2010-12-16 | Type of plan entity | Single employer plan |
| 2010-12-16 | Submission has been amended | No |
| 2010-12-16 | This submission is the final filing | No |
| 2010-12-16 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2010-12-16 | Plan is a collectively bargained plan | No |
| 2010-12-16 | Plan funding arrangement – Insurance | Yes |
| 2010-12-16 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2010-12-16 | Plan benefit arrangement – Insurance | Yes |
| 2010-12-16 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2009: CAP SERVICES, INC. SECTION 125 PLAN 2009 form 5500 responses |
|---|
| 2009-12-16 | Type of plan entity | Single employer plan |
| 2009-12-16 | Submission has been amended | No |
| 2009-12-16 | This submission is the final filing | No |
| 2009-12-16 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2009-12-16 | Plan is a collectively bargained plan | No |
| 2009-12-16 | Plan funding arrangement – Insurance | Yes |
| 2009-12-16 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2009-12-16 | Plan benefit arrangement – Insurance | Yes |
| 2009-12-16 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2008: CAP SERVICES, INC. SECTION 125 PLAN 2008 form 5500 responses |
|---|
| 2008-12-16 | Type of plan entity | Single employer plan |
| 2008-12-16 | Submission has been amended | No |
| 2008-12-16 | This submission is the final filing | No |
| 2008-12-16 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2008-12-16 | Plan is a collectively bargained plan | No |
| 2008-12-16 | Plan funding arrangement – Insurance | Yes |
| 2008-12-16 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2008-12-16 | Plan benefit arrangement – Insurance | Yes |
| 2008-12-16 | Plan benefit arrangement – General assets of the sponsor | Yes |
| WYSSTA INSURANCE COMPANY INC. (National Association of Insurance Commissioners NAIC id number: 12352 ) |
| Policy contract number | 40818 00000 |
| Policy instance | 3 |
| Insurance contract or identification number | 40818 00000 | | Number of Individuals Covered | 97 | | Insurance policy start date | 2022-12-01 | | Insurance policy end date | 2023-11-30 | | Total amount of commissions paid to insurance broker | USD $923 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $11,543 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $923 | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 603615 603616 |
| Policy instance | 2 |
| Insurance contract or identification number | 603615 603616 | | Number of Individuals Covered | 189 | | Insurance policy start date | 2022-12-01 | | Insurance policy end date | 2023-11-30 | | Total amount of commissions paid to insurance broker | USD $6,386 | | Total amount of fees paid to insurance company | USD $1,059 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT, VOL. LIFE | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $52,957 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,386 | | Amount paid for insurance broker fees | 1059 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION PAID | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL OF WISCONSIN (National Association of Insurance Commissioners NAIC id number: 54046 ) |
| Policy contract number | 05911 00000 |
| Policy instance | 1 |
| Insurance contract or identification number | 05911 00000 | | Number of Individuals Covered | 120 | | Insurance policy start date | 2022-12-01 | | Insurance policy end date | 2023-11-30 | | Total amount of commissions paid to insurance broker | USD $1,194 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,194 | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL OF WISCONSIN (National Association of Insurance Commissioners NAIC id number: 54046 ) |
| Policy contract number | 05911 00000 |
| Policy instance | 1 |
| Insurance contract or identification number | 05911 00000 | | Number of Individuals Covered | 119 | | Insurance policy start date | 2021-12-01 | | Insurance policy end date | 2022-11-30 | | Total amount of commissions paid to insurance broker | USD $1,176 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,176 | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 603614 |
| Policy instance | 2 |
| Insurance contract or identification number | 603614 | | Number of Individuals Covered | 193 | | Insurance policy start date | 2021-12-01 | | Insurance policy end date | 2022-11-30 | | Total amount of commissions paid to insurance broker | USD $5,428 | | Total amount of fees paid to insurance company | USD $882 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEALTH & DISMEMBERMENT, VOLUNTARY LIFE AND ACCIDENTAL DEATH & DISMEMBERMENT | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $44,106 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,428 | | Amount paid for insurance broker fees | 882 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION PAID | | Insurance broker organization code? | 3 |
|
| WISCONSIN PHYSICIANS SERVICE INSURANCE CORPORATION (National Association of Insurance Commissioners NAIC id number: 53139 ) |
| Policy contract number | 10011691 |
| Policy instance | 3 |
| Insurance contract or identification number | 10011691 | | Number of Individuals Covered | 66 | | Insurance policy start date | 2021-12-01 | | Insurance policy end date | 2022-11-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | 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 number | 40818 00000 |
| Policy instance | 4 |
| Insurance contract or identification number | 40818 00000 | | Number of Individuals Covered | 92 | | Insurance policy start date | 2021-12-01 | | Insurance policy end date | 2022-11-30 | | Total amount of commissions paid to insurance broker | USD $854 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $10,679 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $854 | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 603614 |
| Policy instance | 2 |
| Insurance contract or identification number | 603614 | | Number of Individuals Covered | 185 | | Insurance policy start date | 2020-12-01 | | Insurance policy end date | 2021-11-30 | | Total amount of commissions paid to insurance broker | USD $5,511 | | Total amount of fees paid to insurance company | USD $894 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | AD&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 Carrier | USD $44,721 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,511 | | Amount paid for insurance broker fees | 894 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION PAID | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL OF WISCONSIN (National Association of Insurance Commissioners NAIC id number: 54046 ) |
| Policy contract number | 05911 |
| Policy instance | 1 |
| Insurance contract or identification number | 05911 | | Number of Individuals Covered | 111 | | Insurance policy start date | 2020-12-01 | | Insurance policy end date | 2021-11-30 | | Total amount of commissions paid to insurance broker | USD $1,236 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,236 | | Insurance broker organization code? | 3 |
|
| WPS HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 10159 ) |
| Policy contract number | 10011691 |
| Policy instance | 3 |
| Insurance contract or identification number | 10011691 | | Number of Individuals Covered | 76 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $550,759 | | 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 number | 40818 |
| Policy instance | 4 |
| Insurance contract or identification number | 40818 | | Number of Individuals Covered | 92 | | Insurance policy start date | 2020-12-01 | | Insurance policy end date | 2021-11-30 | | Total amount of commissions paid to insurance broker | USD $933 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $11,666 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $933 | | Insurance broker organization code? | 3 |
|
| WISCONSIN PHYSICIANS SERVICE INSURANCE CORPORATION (National Association of Insurance Commissioners NAIC id number: 53139 ) |
| Policy contract number | 10011691 |
| Policy instance | 3 |
| Insurance contract or identification number | 10011691 | | Number of Individuals Covered | 152 | | Insurance policy start date | 2019-12-01 | | Insurance policy end date | 2020-11-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 603614 |
| Policy instance | 2 |
| Insurance contract or identification number | 603614 | | Number of Individuals Covered | 200 | | Insurance policy start date | 2019-12-01 | | Insurance policy end date | 2020-11-30 | | Total amount of commissions paid to insurance broker | USD $5,361 | | Total amount of fees paid to insurance company | USD $868 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $43,397 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,361 | | Amount paid for insurance broker fees | 868 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION PAID | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL OF WISCONSIN (National Association of Insurance Commissioners NAIC id number: 54046 ) |
| Policy contract number | 05911 00000 |
| Policy instance | 1 |
| Insurance contract or identification number | 05911 00000 | | Number of Individuals Covered | 115 | | Insurance policy start date | 2019-12-01 | | Insurance policy end date | 2020-11-30 | | Total amount of commissions paid to insurance broker | USD $1,246 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,246 | | Insurance broker organization code? | 3 |
|
| WYSSTA INSURANCE COMPANY INC. (National Association of Insurance Commissioners NAIC id number: 12352 ) |
| Policy contract number | 40818 00000 |
| Policy instance | 4 |
| Insurance contract or identification number | 40818 00000 | | Number of Individuals Covered | 95 | | Insurance policy start date | 2019-12-01 | | Insurance policy end date | 2020-11-30 | | Total amount of commissions paid to insurance broker | USD $910 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $10,881 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $910 | | Insurance broker organization code? | 3 |
|
| WYSSTA INSURANCE COMPANY INC. (National Association of Insurance Commissioners NAIC id number: 12352 ) |
| Policy contract number | 40818 |
| Policy instance | 4 |
| Insurance contract or identification number | 40818 | | Number of Individuals Covered | 92 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $821 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $10,264 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $821 | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL OF WISCONSIN (National Association of Insurance Commissioners NAIC id number: 54046 ) |
| Policy contract number | 05911 00000 |
| Policy instance | 1 |
| Insurance contract or identification number | 05911 00000 | | Number of Individuals Covered | 121 | | Insurance policy start date | 2018-12-01 | | Insurance policy end date | 2019-11-30 | | Total amount of commissions paid to insurance broker | USD $1,225 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,225 | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 603614 |
| Policy instance | 3 |
| Insurance contract or identification number | 603614 | | Number of Individuals Covered | 100 | | Insurance policy start date | 2018-12-01 | | Insurance policy end date | 2019-11-30 | | Total amount of commissions paid to insurance broker | USD $3,103 | | Total amount of fees paid to insurance company | USD $498 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $24,913 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,985 | | Amount paid for insurance broker fees | 813 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION PAID | | Insurance broker organization code? | 3 |
|
| WISCONSIN PHYSICIANS SERVICE INSURANCE CORPORATION (National Association of Insurance Commissioners NAIC id number: 53139 ) |
| Policy contract number | 10011691 |
| Policy instance | 2 |
| Insurance contract or identification number | 10011691 | | Number of Individuals Covered | 251 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $909,043 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| DELTA DENTAL OF WISCONSIN (National Association of Insurance Commissioners NAIC id number: 54046 ) |
| Policy contract number | 05911 |
| Policy instance | 1 |
| Insurance contract or identification number | 05911 | | Number of Individuals Covered | 122 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $1,225 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,225 | | Insurance broker organization code? | 3 |
|
| WYSSTA INSURANCE COMPANY INC. (National Association of Insurance Commissioners NAIC id number: 12352 ) |
| Policy contract number | 40818 00000 |
| Policy instance | 4 |
| Insurance contract or identification number | 40818 00000 | | Number of Individuals Covered | 9293 | | Insurance policy start date | 2018-12-01 | | Insurance policy end date | 2019-11-30 | | Total amount of commissions paid to insurance broker | USD $815 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $10,190 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $815 | | Insurance broker organization code? | 3 |
|
| WYSSTA INSURANCE COMPANY INC. (National Association of Insurance Commissioners NAIC id number: 12352 ) |
| Policy contract number | 40818 00000 |
| Policy instance | 5 |
| Insurance contract or identification number | 40818 00000 | | Number of Individuals Covered | 80 | | Insurance policy start date | 2017-12-01 | | Insurance policy end date | 2018-11-30 | | Total amount of commissions paid to insurance broker | USD $779 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $9,735 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $779 | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL OF WISCONSIN (National Association of Insurance Commissioners NAIC id number: 54046 ) |
| Policy contract number | 05911 00000 |
| Policy instance | 1 |
| Insurance contract or identification number | 05911 00000 | | Number of Individuals Covered | 116 | | Insurance policy start date | 2017-12-01 | | Insurance policy end date | 2018-11-30 | | Total amount of commissions paid to insurance broker | USD $1,333 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,333 | | Insurance broker organization code? | 3 |
|
| WISCONSIN PHYSICIANS SERVICE INSURANCE CORPORATION (National Association of Insurance Commissioners NAIC id number: 53139 ) |
| Policy contract number | 10011691 |
| Policy instance | 4 |
| Insurance contract or identification number | 10011691 | | Number of Individuals Covered | 150 | | Insurance policy start date | 2018-08-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $336,963 | | 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 number | 40818 |
| Policy instance | 5 |
| Insurance contract or identification number | 40818 | | Number of Individuals Covered | 83 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $788 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $9,846 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 603614 |
| Policy instance | 3 |
| Insurance contract or identification number | 603614 | | Number of Individuals Covered | 98 | | Insurance policy start date | 2017-12-01 | | Insurance policy end date | 2018-11-30 | | Total amount of commissions paid to insurance broker | USD $5,476 | | Total amount of fees paid to insurance company | USD $909 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $45,458 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,569 | | Amount paid for insurance broker fees | 926 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION PAID | | Insurance broker organization code? | 3 |
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| DELTA DENTAL OF WISCONSIN (National Association of Insurance Commissioners NAIC id number: 54046 ) |
| Policy contract number | 05911 |
| Policy instance | 1 |
| Insurance contract or identification number | 05911 | | Number of Individuals Covered | 120 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $1,333 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $104,582 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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| NETWORK HEALTH INC (National Association of Insurance Commissioners NAIC id number: 95737 ) |
| Policy contract number | 2000839 |
| Policy instance | 2 |
| Insurance contract or identification number | 2000839 | | Number of Individuals Covered | 79 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-07-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $473,034 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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