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REGENCY TERRACE SOUTH, INC. D/B/A HALES CORNER CARE CENTER WELFARE BENEFIT PLAN 401k Plan overview

Plan NameREGENCY TERRACE SOUTH, INC. D/B/A HALES CORNER CARE CENTER WELFARE BENEFIT PLAN
Plan identification number 501

REGENCY TERRACE SOUTH, INC. D/B/A HALES CORNER CARE CENTER WELFARE BENEFIT PLAN Benefits

401k Plan TypeWelfare Benefit
Plan Features/Benefits
  • Health (other than dental or vision)
  • Life insurance
  • Dental
  • Vision
  • Long-term disability cover

401k Sponsoring company profile

REGENCY TERRACE SOUTH, INC. D/B/A HALES CORNER CARE CENTER has sponsored the creation of one or more 401k plans.

Company Name:REGENCY TERRACE SOUTH, INC. D/B/A HALES CORNER CARE CENTER
Employer identification number (EIN):391098276
NAIC Classification:623000
NAIC Description: Nursing and Residential Care Facilities

Form 5500 Filing Information

Submission information for form 5500 for 401k plan REGENCY TERRACE SOUTH, INC. D/B/A HALES CORNER CARE CENTER WELFARE BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5012022-07-01THADDEUS DERYNDA2023-12-12
5012021-07-01THADDEUS DERYNFA2023-04-18
5012020-07-01PATRICK MURPHY2022-04-15
5012019-07-01PATRICK MURPHY2021-04-15
5012018-07-01THADDEUS DERYNDA2020-04-13
5012017-07-01
5012016-07-01
5012015-07-01
5012014-07-01
5012013-07-01JOHN B. SAUER
5012012-07-01JOHN B. SAUER
5012011-07-01JOHN B. SAUER
5012010-07-01JOHN B. SAUER
5012009-07-01JOHN B. SAUER
5012007-07-01JOHN B. SAUER

Plan Statistics for REGENCY TERRACE SOUTH, INC. D/B/A HALES CORNER CARE CENTER WELFARE BENEFIT PLAN

401k plan membership statisitcs for REGENCY TERRACE SOUTH, INC. D/B/A HALES CORNER CARE CENTER WELFARE BENEFIT PLAN

Measure Date Value
2022: REGENCY TERRACE SOUTH, INC. D/B/A HALES CORNER CARE CENTER WELFARE BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year2022-07-010
Total number of active participants reported on line 7a of the Form 55002022-07-010
Number of retired or separated participants receiving benefits2022-07-010
Number of other retired or separated participants entitled to future benefits2022-07-010
Total of all active and inactive participants2022-07-010
2021: REGENCY TERRACE SOUTH, INC. D/B/A HALES CORNER CARE CENTER WELFARE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year2021-07-010
Total number of active participants reported on line 7a of the Form 55002021-07-010
Number of retired or separated participants receiving benefits2021-07-010
Number of other retired or separated participants entitled to future benefits2021-07-010
Total of all active and inactive participants2021-07-010
2020: REGENCY TERRACE SOUTH, INC. D/B/A HALES CORNER CARE CENTER WELFARE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year2020-07-010
Total number of active participants reported on line 7a of the Form 55002020-07-010
Number of retired or separated participants receiving benefits2020-07-010
Number of other retired or separated participants entitled to future benefits2020-07-010
Total of all active and inactive participants2020-07-010
2019: REGENCY TERRACE SOUTH, INC. D/B/A HALES CORNER CARE CENTER WELFARE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year2019-07-010
Total number of active participants reported on line 7a of the Form 55002019-07-010
Number of retired or separated participants receiving benefits2019-07-010
Number of other retired or separated participants entitled to future benefits2019-07-010
Total of all active and inactive participants2019-07-010
2018: REGENCY TERRACE SOUTH, INC. D/B/A HALES CORNER CARE CENTER WELFARE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year2018-07-010
Total number of active participants reported on line 7a of the Form 55002018-07-010
Number of retired or separated participants receiving benefits2018-07-010
Number of other retired or separated participants entitled to future benefits2018-07-010
Total of all active and inactive participants2018-07-010
2017: REGENCY TERRACE SOUTH, INC. D/B/A HALES CORNER CARE CENTER WELFARE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year2017-07-010
Total number of active participants reported on line 7a of the Form 55002017-07-010
Number of retired or separated participants receiving benefits2017-07-010
Number of other retired or separated participants entitled to future benefits2017-07-010
Total of all active and inactive participants2017-07-010
2016: REGENCY TERRACE SOUTH, INC. D/B/A HALES CORNER CARE CENTER WELFARE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year2016-07-010
Total number of active participants reported on line 7a of the Form 55002016-07-010
Number of retired or separated participants receiving benefits2016-07-010
Number of other retired or separated participants entitled to future benefits2016-07-010
Total of all active and inactive participants2016-07-010
2015: REGENCY TERRACE SOUTH, INC. D/B/A HALES CORNER CARE CENTER WELFARE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year2015-07-01434
Total number of active participants reported on line 7a of the Form 55002015-07-010
Number of retired or separated participants receiving benefits2015-07-010
Number of other retired or separated participants entitled to future benefits2015-07-010
Total of all active and inactive participants2015-07-010
2014: REGENCY TERRACE SOUTH, INC. D/B/A HALES CORNER CARE CENTER WELFARE BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year2014-07-01247
Total number of active participants reported on line 7a of the Form 55002014-07-010
Number of retired or separated participants receiving benefits2014-07-010
Number of other retired or separated participants entitled to future benefits2014-07-010
Total of all active and inactive participants2014-07-010
2013: REGENCY TERRACE SOUTH, INC. D/B/A HALES CORNER CARE CENTER WELFARE BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year2013-07-01234
Total number of active participants reported on line 7a of the Form 55002013-07-010
Number of retired or separated participants receiving benefits2013-07-010
Number of other retired or separated participants entitled to future benefits2013-07-010
Total of all active and inactive participants2013-07-010
2012: REGENCY TERRACE SOUTH, INC. D/B/A HALES CORNER CARE CENTER WELFARE BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year2012-07-01210
Total number of active participants reported on line 7a of the Form 55002012-07-01210
Number of retired or separated participants receiving benefits2012-07-010
Number of other retired or separated participants entitled to future benefits2012-07-010
Total of all active and inactive participants2012-07-01210
2011: REGENCY TERRACE SOUTH, INC. D/B/A HALES CORNER CARE CENTER WELFARE BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year2011-07-01189
Total number of active participants reported on line 7a of the Form 55002011-07-010
Number of retired or separated participants receiving benefits2011-07-010
Number of other retired or separated participants entitled to future benefits2011-07-010
Total of all active and inactive participants2011-07-010
2010: REGENCY TERRACE SOUTH, INC. D/B/A HALES CORNER CARE CENTER WELFARE BENEFIT PLAN 2010 401k membership
Total participants, beginning-of-year2010-07-01247
Total number of active participants reported on line 7a of the Form 55002010-07-01262
Number of retired or separated participants receiving benefits2010-07-010
Number of other retired or separated participants entitled to future benefits2010-07-010
Total of all active and inactive participants2010-07-01262
2009: REGENCY TERRACE SOUTH, INC. D/B/A HALES CORNER CARE CENTER WELFARE BENEFIT PLAN 2009 401k membership
Total participants, beginning-of-year2009-07-01243
Total number of active participants reported on line 7a of the Form 55002009-07-01247
Number of retired or separated participants receiving benefits2009-07-010
Number of other retired or separated participants entitled to future benefits2009-07-010
Total of all active and inactive participants2009-07-01247
2007: REGENCY TERRACE SOUTH, INC. D/B/A HALES CORNER CARE CENTER WELFARE BENEFIT PLAN 2007 401k membership
Total number of active participants reported on line 7a of the Form 55002007-07-01357
Number of retired or separated participants receiving benefits2007-07-010
Number of other retired or separated participants entitled to future benefits2007-07-010
Total of all active and inactive participants2007-07-01357

Form 5500 Responses for REGENCY TERRACE SOUTH, INC. D/B/A HALES CORNER CARE CENTER WELFARE BENEFIT PLAN

2022: REGENCY TERRACE SOUTH, INC. D/B/A HALES CORNER CARE CENTER WELFARE BENEFIT PLAN 2022 form 5500 responses
2022-07-01Type of plan entitySingle employer plan
2022-07-01Submission has been amendedNo
2022-07-01This submission is the final filingNo
2022-07-01This return/report is a short plan year return/report (less than 12 months)No
2022-07-01Plan is a collectively bargained planNo
2022-07-01Plan funding arrangement – InsuranceYes
2022-07-01Plan benefit arrangement – InsuranceYes
2021: REGENCY TERRACE SOUTH, INC. D/B/A HALES CORNER CARE CENTER WELFARE BENEFIT PLAN 2021 form 5500 responses
2021-07-01Type of plan entitySingle employer plan
2021-07-01Submission has been amendedNo
2021-07-01This submission is the final filingNo
2021-07-01This return/report is a short plan year return/report (less than 12 months)No
2021-07-01Plan is a collectively bargained planNo
2021-07-01Plan funding arrangement – InsuranceYes
2021-07-01Plan benefit arrangement – InsuranceYes
2020: REGENCY TERRACE SOUTH, INC. D/B/A HALES CORNER CARE CENTER WELFARE BENEFIT PLAN 2020 form 5500 responses
2020-07-01Type of plan entitySingle employer plan
2020-07-01Submission has been amendedNo
2020-07-01This submission is the final filingNo
2020-07-01This return/report is a short plan year return/report (less than 12 months)No
2020-07-01Plan is a collectively bargained planNo
2020-07-01Plan funding arrangement – InsuranceYes
2020-07-01Plan benefit arrangement – InsuranceYes
2019: REGENCY TERRACE SOUTH, INC. D/B/A HALES CORNER CARE CENTER WELFARE BENEFIT PLAN 2019 form 5500 responses
2019-07-01Type of plan entitySingle employer plan
2019-07-01Submission has been amendedNo
2019-07-01This submission is the final filingNo
2019-07-01This return/report is a short plan year return/report (less than 12 months)No
2019-07-01Plan is a collectively bargained planNo
2019-07-01Plan funding arrangement – InsuranceYes
2019-07-01Plan benefit arrangement – InsuranceYes
2018: REGENCY TERRACE SOUTH, INC. D/B/A HALES CORNER CARE CENTER WELFARE BENEFIT PLAN 2018 form 5500 responses
2018-07-01Type of plan entitySingle employer plan
2018-07-01Submission has been amendedNo
2018-07-01This submission is the final filingNo
2018-07-01This return/report is a short plan year return/report (less than 12 months)No
2018-07-01Plan is a collectively bargained planNo
2018-07-01Plan funding arrangement – InsuranceYes
2018-07-01Plan benefit arrangement – InsuranceYes
2017: REGENCY TERRACE SOUTH, INC. D/B/A HALES CORNER CARE CENTER WELFARE BENEFIT PLAN 2017 form 5500 responses
2017-07-01Type of plan entitySingle employer plan
2017-07-01Submission has been amendedNo
2017-07-01This submission is the final filingNo
2017-07-01This return/report is a short plan year return/report (less than 12 months)No
2017-07-01Plan is a collectively bargained planNo
2017-07-01Plan funding arrangement – InsuranceYes
2017-07-01Plan benefit arrangement – InsuranceYes
2016: REGENCY TERRACE SOUTH, INC. D/B/A HALES CORNER CARE CENTER WELFARE BENEFIT PLAN 2016 form 5500 responses
2016-07-01Type of plan entitySingle employer plan
2016-07-01Submission has been amendedNo
2016-07-01This submission is the final filingNo
2016-07-01This return/report is a short plan year return/report (less than 12 months)No
2016-07-01Plan is a collectively bargained planNo
2016-07-01Plan funding arrangement – InsuranceYes
2016-07-01Plan benefit arrangement – InsuranceYes
2015: REGENCY TERRACE SOUTH, INC. D/B/A HALES CORNER CARE CENTER WELFARE BENEFIT PLAN 2015 form 5500 responses
2015-07-01Type of plan entitySingle employer plan
2015-07-01Submission has been amendedNo
2015-07-01This submission is the final filingNo
2015-07-01This return/report is a short plan year return/report (less than 12 months)No
2015-07-01Plan is a collectively bargained planNo
2015-07-01Plan funding arrangement – InsuranceYes
2015-07-01Plan benefit arrangement – InsuranceYes
2014: REGENCY TERRACE SOUTH, INC. D/B/A HALES CORNER CARE CENTER WELFARE BENEFIT PLAN 2014 form 5500 responses
2014-07-01Type of plan entitySingle employer plan
2014-07-01Submission has been amendedNo
2014-07-01This submission is the final filingNo
2014-07-01This return/report is a short plan year return/report (less than 12 months)No
2014-07-01Plan is a collectively bargained planNo
2014-07-01Plan funding arrangement – InsuranceYes
2014-07-01Plan benefit arrangement – InsuranceYes
2013: REGENCY TERRACE SOUTH, INC. D/B/A HALES CORNER CARE CENTER WELFARE BENEFIT PLAN 2013 form 5500 responses
2013-07-01Type of plan entitySingle employer plan
2013-07-01Submission has been amendedNo
2013-07-01This submission is the final filingNo
2013-07-01This return/report is a short plan year return/report (less than 12 months)No
2013-07-01Plan is a collectively bargained planNo
2013-07-01Plan funding arrangement – InsuranceYes
2013-07-01Plan benefit arrangement – InsuranceYes
2012: REGENCY TERRACE SOUTH, INC. D/B/A HALES CORNER CARE CENTER WELFARE BENEFIT PLAN 2012 form 5500 responses
2012-07-01Type of plan entitySingle employer plan
2012-07-01Submission has been amendedNo
2012-07-01This submission is the final filingNo
2012-07-01This return/report is a short plan year return/report (less than 12 months)No
2012-07-01Plan is a collectively bargained planNo
2012-07-01Plan funding arrangement – InsuranceYes
2012-07-01Plan benefit arrangement – InsuranceYes
2011: REGENCY TERRACE SOUTH, INC. D/B/A HALES CORNER CARE CENTER WELFARE BENEFIT PLAN 2011 form 5500 responses
2011-07-01Type of plan entitySingle employer plan
2011-07-01Submission has been amendedNo
2011-07-01This submission is the final filingNo
2011-07-01This return/report is a short plan year return/report (less than 12 months)No
2011-07-01Plan is a collectively bargained planNo
2011-07-01Plan funding arrangement – InsuranceYes
2011-07-01Plan benefit arrangement – InsuranceYes
2010: REGENCY TERRACE SOUTH, INC. D/B/A HALES CORNER CARE CENTER WELFARE BENEFIT PLAN 2010 form 5500 responses
2010-07-01Type of plan entitySingle employer plan
2010-07-01Submission has been amendedNo
2010-07-01This submission is the final filingNo
2010-07-01This return/report is a short plan year return/report (less than 12 months)No
2010-07-01Plan is a collectively bargained planNo
2010-07-01Plan funding arrangement – InsuranceYes
2010-07-01Plan benefit arrangement – InsuranceYes
2009: REGENCY TERRACE SOUTH, INC. D/B/A HALES CORNER CARE CENTER WELFARE BENEFIT PLAN 2009 form 5500 responses
2009-07-01Type of plan entitySingle employer plan
2009-07-01Submission has been amendedNo
2009-07-01This submission is the final filingNo
2009-07-01This return/report is a short plan year return/report (less than 12 months)No
2009-07-01Plan is a collectively bargained planNo
2009-07-01Plan funding arrangement – InsuranceYes
2009-07-01Plan benefit arrangement – InsuranceYes
2007: REGENCY TERRACE SOUTH, INC. D/B/A HALES CORNER CARE CENTER WELFARE BENEFIT PLAN 2007 form 5500 responses
2007-07-01Submission has been amendedNo
2007-07-01This submission is the final filingNo
2007-07-01This return/report is a short plan year return/report (less than 12 months)No
2007-07-01Plan is a collectively bargained planNo
2007-07-01Plan funding arrangement – InsuranceYes
2007-07-01Plan benefit arrangement – InsuranceYes

Insurance Providers Used on plan

WPS HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 10159 )
Policy contract number10012293
Policy instance 9
Insurance contract or identification number10012293
Number of Individuals Covered99
Insurance policy start date2022-07-01
Insurance policy end date2023-06-30
Total amount of commissions paid to insurance brokerUSD $25,306
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare 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 $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $25,306
Insurance broker organization code?3
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number905453
Policy instance 1
Insurance contract or identification number905453
Number of Individuals Covered132
Insurance policy start date2022-07-01
Insurance policy end date2023-06-30
Total amount of commissions paid to insurance brokerUSD $2,145
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,145
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerSERVICE FEE AGREEMENT
Insurance broker organization code?3
DIVERSITY BENEFIT SERVICE, INC. (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number00000
Policy instance 2
Insurance contract or identification number00000
Number of Individuals Covered5
Insurance policy start date2022-07-01
Insurance policy end date2023-06-30
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $751
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedFLEXIBLE BENEFIT
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 $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Amount paid for insurance broker fees751
Additional information about fees paid to insurance brokerADMIN FEE
Insurance broker organization code?0
DIVERSITY BENEFIT SERVICE, INC. (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number00000
Policy instance 3
Insurance contract or identification number00000
Number of Individuals Covered36
Insurance policy start date2022-07-01
Insurance policy end date2023-06-30
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $2,345
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedHEALTH REIMBURSEMENT ARRANGEMENT
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 $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Amount paid for insurance broker fees2345
Additional information about fees paid to insurance brokerADMIN FEES
Insurance broker organization code?0
DIVERSITY BENEFIT SERVICE, INC. (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number0000
Policy instance 4
Insurance contract or identification number0000
Number of Individuals Covered4
Insurance policy start date2022-07-01
Insurance policy end date2023-06-30
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $896
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedFLEXIBLE BENEFIT
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 $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Amount paid for insurance broker fees896
Additional information about fees paid to insurance brokerADMIN FEES
Insurance broker organization code?0
DIVERSITY BENEFIT SERVICE, INC. (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number00000
Policy instance 5
Insurance contract or identification number00000
Number of Individuals Covered37
Insurance policy start date2022-07-01
Insurance policy end date2023-06-30
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $2,387
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedHEALTH REIMBURSEMENT ARRANGEMENT
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 $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Amount paid for insurance broker fees2387
Additional information about fees paid to insurance brokerADMIN FEES
Insurance broker organization code?0
DIVERSITY BENEFIT SERVICE, INC. (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number94200447
Policy instance 6
Insurance contract or identification number94200447
Number of Individuals Covered308
Insurance policy start date2022-07-01
Insurance policy end date2023-06-30
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $3,274
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedEAP
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 $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Amount paid for insurance broker fees3274
Additional information about fees paid to insurance brokerSERVICE FEES
Insurance broker organization code?0
DELTA DENTAL OF WISCONSIN (National Association of Insurance Commissioners NAIC id number: 54046 )
Policy contract number11717
Policy instance 7
Insurance contract or identification number11717
Number of Individuals Covered48
Insurance policy start date2022-07-01
Insurance policy end date2023-06-30
Total amount of commissions paid to insurance brokerUSD $2,040
Total amount of fees paid to insurance companyUSD $4,197
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare 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 $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,040
Amount paid for insurance broker fees4197
Additional information about fees paid to insurance brokerOTHER FEES
Insurance broker organization code?3
WISCONSIN PHYSICIANS SERVICE INSURANCE CORPORATION (National Association of Insurance Commissioners NAIC id number: 53139 )
Policy contract number100122936
Policy instance 8
Insurance contract or identification number100122936
Number of Individuals Covered47
Insurance policy start date2022-07-01
Insurance policy end date2023-06-30
Total amount of commissions paid to insurance brokerUSD $12,526
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare 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 $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $12,526
Insurance broker organization code?3
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number905453
Policy instance 1
Insurance contract or identification number905453
Number of Individuals Covered430
Insurance policy start date2021-07-01
Insurance policy end date2022-06-30
Total amount of commissions paid to insurance brokerUSD $10,380
Total amount of fees paid to insurance companyUSD $62,350
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $10,380
Amount paid for insurance broker fees62350
Additional information about fees paid to insurance brokerSERVICE FEE AGREEMENT
Insurance broker organization code?3
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number905453
Policy instance 1
Insurance contract or identification number905453
Number of Individuals Covered430
Insurance policy start date2020-07-01
Insurance policy end date2021-06-30
Total amount of commissions paid to insurance brokerUSD $10,380
Total amount of fees paid to insurance companyUSD $62,350
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $10,380
Amount paid for insurance broker fees62350
Additional information about fees paid to insurance brokerSERVICE FEE AGREEMENT
Insurance broker organization code?3
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number905453
Policy instance 1
Insurance contract or identification number905453
Number of Individuals Covered445
Insurance policy start date2019-07-01
Insurance policy end date2020-06-30
Total amount of commissions paid to insurance brokerUSD $9,145
Total amount of fees paid to insurance companyUSD $65,400
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $9,145
Amount paid for insurance broker fees65400
Additional information about fees paid to insurance brokerSERVICE FEE AGREEMENT
Insurance broker organization code?3
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number905453
Policy instance 1
Insurance contract or identification number905453
Number of Individuals Covered445
Insurance policy start date2018-07-01
Insurance policy end date2019-06-30
Total amount of commissions paid to insurance brokerUSD $9,145
Total amount of fees paid to insurance companyUSD $65,400
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $9,145
Amount paid for insurance broker fees65400
Additional information about fees paid to insurance brokerSERVICE FEE AGREEMENT
Insurance broker organization code?3
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number905453
Policy instance 1
Insurance contract or identification number905453
Number of Individuals Covered333
Insurance policy start date2017-07-01
Insurance policy end date2018-06-30
Total amount of commissions paid to insurance brokerUSD $5,310
Total amount of fees paid to insurance companyUSD $63,679
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number905453
Policy instance 1
Insurance contract or identification number905453
Number of Individuals Covered434
Insurance policy start date2015-07-01
Insurance policy end date2016-06-30
Total amount of commissions paid to insurance brokerUSD $9,638
Total amount of fees paid to insurance companyUSD $59,535
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 BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $2,123,010
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $9,638
Amount paid for insurance broker fees59535
Additional information about fees paid to insurance brokerSERVICE FEE AGREEMENT
Insurance broker organization code?3
Insurance broker nameMARSH & MCLENNAN AGENCY LLC
HUMANA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 73288 )
Policy contract number717181
Policy instance 1
Insurance contract or identification number717181
Number of Individuals Covered247
Insurance policy start date2014-07-01
Insurance policy end date2015-06-30
Total amount of commissions paid to insurance brokerUSD $104,146
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 BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $2,112,724
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $51,678
Insurance broker organization code?3
Insurance broker nameFRANK P. ORZEL & COMPANY
HUMANA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 73288 )
Policy contract number717181
Policy instance 1
Insurance contract or identification number717181
Number of Individuals Covered234
Insurance policy start date2013-07-01
Insurance policy end date2014-06-30
Total amount of commissions paid to insurance brokerUSD $77,794
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 BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $2,198,466
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $39,742
Insurance broker organization code?3
Insurance broker nameFRANK P. ORZEL & COMPANY
HUMANA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 73288 )
Policy contract number717181
Policy instance 1
Insurance contract or identification number717181
Number of Individuals Covered210
Insurance policy start date2012-07-01
Insurance policy end date2013-06-30
Total amount of commissions paid to insurance brokerUSD $75,453
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 BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $2,119,849
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $37,738
Insurance broker organization code?3
Insurance broker nameFIRST BENEFITS CORPORATION
HUMANA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 73288 )
Policy contract number717181
Policy instance 1
Insurance contract or identification number717181
Number of Individuals Covered189
Insurance policy start date2011-07-01
Insurance policy end date2012-06-30
Total amount of commissions paid to insurance brokerUSD $73,379
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 BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $1,829,790
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
HUMANA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 73288 )
Policy contract number717181
Policy instance 1
Insurance contract or identification number717181
Number of Individuals Covered262
Insurance policy start date2010-07-01
Insurance policy end date2011-06-30
Total amount of commissions paid to insurance brokerUSD $70,685
Total amount of fees paid to insurance companyUSD $522
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 BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $1,764,952
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract numberKM05712855
Policy instance 1
Insurance contract or identification numberKM05712855
Number of Individuals Covered0
Insurance policy start date2008-07-01
Insurance policy end date2009-06-30
Total amount of commissions paid to insurance brokerUSD $198
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 BenefitYes
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $99
Insurance broker organization code?3
Insurance broker nameFIRST BENEFITS CORPORATION
HUMANA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 73288 )
Policy contract number717181
Policy instance 2
Insurance contract or identification number717181
Number of Individuals Covered243
Insurance policy start date2008-07-01
Insurance policy end date2009-06-30
Total amount of commissions paid to insurance brokerUSD $43,544
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 $1,058,171
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $21,769
Insurance broker organization code?3
Insurance broker nameFIRST BENEFITS CORPORATION
WISCONSIN PHYSICIANS SERVICE INSURANCE CORPORATION (National Association of Insurance Commissioners NAIC id number: 53139 )
Policy contract number146406
Policy instance 2
Insurance contract or identification number146406
Number of Individuals Covered140
Insurance policy start date2007-07-01
Insurance policy end date2008-06-30
Total amount of commissions paid to insurance brokerUSD $46,485
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $46,485
Insurance broker organization code?3
Insurance broker nameCYGANIAK PLANNING, INC.
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract numberKM05712855
Policy instance 1
Insurance contract or identification numberKM05712855
Number of Individuals Covered357
Insurance policy start date2007-07-01
Insurance policy end date2008-06-30
Total amount of commissions paid to insurance brokerUSD $4,402
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 BenefitYes
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 $94,084
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,201
Insurance broker organization code?3
Insurance broker nameFIRST BENEFITS CORPORATION
WISCONSIN PHYSICIANS SERVICE INSURANCE CORPORATION (National Association of Insurance Commissioners NAIC id number: 53139 )
Policy contract number146406
Policy instance 3
Insurance contract or identification number146406
Number of Individuals Covered139
Insurance policy start date2006-07-01
Insurance policy end date2007-06-30
Total amount of commissions paid to insurance brokerUSD $49,877
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $49,877
Insurance broker organization code?3
Insurance broker nameCYGANIAK PLANNING, INC.
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number00286313
Policy instance 2
Insurance contract or identification number00286313
Number of Individuals Covered149
Insurance policy start date2006-07-01
Insurance policy end date2007-06-30
Total amount of commissions paid to insurance brokerUSD $3,326
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 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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,645
Insurance broker organization code?3
Insurance broker nameTHE HUNKEN AGENCY, INC.
THE EPIC LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64149 )
Policy contract number146406
Policy instance 1
Insurance contract or identification number146406
Number of Individuals Covered180
Insurance policy start date2006-07-01
Insurance policy end date2007-06-30
Total amount of commissions paid to insurance brokerUSD $1,495
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,495
Insurance broker organization code?3
Insurance broker nameCYGANIAK PLANNING, INC.
WISCONSIN PHYSICIANS SERVICE INSURANCE CORPORATION (National Association of Insurance Commissioners NAIC id number: 53139 )
Policy contract number146406
Policy instance 3
Insurance contract or identification number146406
Number of Individuals Covered127
Insurance policy start date2005-07-01
Insurance policy end date2006-06-30
Total amount of commissions paid to insurance brokerUSD $33,568
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $33,568
Insurance broker organization code?3
Insurance broker nameCYGANIAK PLANNING, INC.
THE EPIC LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64149 )
Policy contract number146406
Policy instance 1
Insurance contract or identification number146406
Number of Individuals Covered160
Insurance policy start date2005-07-01
Insurance policy end date2006-06-30
Total amount of commissions paid to insurance brokerUSD $1,362
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,362
Insurance broker organization code?3
Insurance broker nameCYGANIAK PLANNING, INC.
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number00286313
Policy instance 2
Insurance contract or identification number00286313
Number of Individuals Covered136
Insurance policy start date2005-07-01
Insurance policy end date2006-06-30
Total amount of commissions paid to insurance brokerUSD $3,154
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 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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,561
Insurance broker organization code?3
Insurance broker nameTHE HUNKEN AGENCY, INC.
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number00286313
Policy instance 2
Insurance contract or identification number00286313
Number of Individuals Covered143
Insurance policy start date2004-07-01
Insurance policy end date2005-06-30
Total amount of commissions paid to insurance brokerUSD $3,214
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 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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,607
Insurance broker organization code?3
Insurance broker nameFRANK P ORZEL
THE EPIC LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64149 )
Policy contract number146406
Policy instance 1
Insurance contract or identification number146406
Number of Individuals Covered193
Insurance policy start date2004-07-01
Insurance policy end date2005-06-30
Total amount of commissions paid to insurance brokerUSD $1,538
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,538
Insurance broker organization code?3
Insurance broker nameCYGANIAK PLANNING, INC.
WISCONSIN PHYSICIANS SERVICE INSURANCE CORPORATION (National Association of Insurance Commissioners NAIC id number: 53139 )
Policy contract number146406
Policy instance 3
Insurance contract or identification number146406
Number of Individuals Covered145
Insurance policy start date2004-07-01
Insurance policy end date2005-06-30
Total amount of commissions paid to insurance brokerUSD $34,967
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $34,967
Insurance broker organization code?3
Insurance broker nameCYGANIAK PLANNING, INC.
THE EPIC LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64149 )
Policy contract number146406
Policy instance 1
Insurance contract or identification number146406
Number of Individuals Covered125
Insurance policy start date2003-07-01
Insurance policy end date2004-06-30
Total amount of commissions paid to insurance brokerUSD $854
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $854
Insurance broker organization code?3
Insurance broker nameCYGANIAK PLANNING, INC.
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number00286313
Policy instance 2
Insurance contract or identification number00286313
Number of Individuals Covered156
Insurance policy start date2003-07-01
Insurance policy end date2004-06-30
Total amount of commissions paid to insurance brokerUSD $3,978
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 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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,989
Insurance broker organization code?3
Insurance broker nameFRANK P ORZEL
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number00286313
Policy instance 2
Insurance contract or identification number00286313
Number of Individuals Covered134
Insurance policy start date2002-07-01
Insurance policy end date2003-06-30
Total amount of commissions paid to insurance brokerUSD $3,752
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 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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $901
Insurance broker organization code?3
Insurance broker nameFRANK P ORZEL
THE EPIC LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64149 )
Policy contract number146406
Policy instance 1
Insurance contract or identification number146406
Number of Individuals Covered125
Insurance policy start date2002-07-01
Insurance policy end date2003-06-30
Total amount of commissions paid to insurance brokerUSD $777
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $777
Insurance broker organization code?3
Insurance broker nameCYGANIAK PLANNING, INC.
THE EPIC LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64149 )
Policy contract number146406
Policy instance 1
Insurance contract or identification number146406
Number of Individuals Covered139
Insurance policy start date2001-07-01
Insurance policy end date2002-06-30
Total amount of commissions paid to insurance brokerUSD $1,290
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,290
Insurance broker organization code?3
Insurance broker nameCYGANIAK PLANNING, INC.

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