EMPIRE SCREEN PRINTING, INC. has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan EMPIRE SCREEN PRINTING INC SECT 125 PREMIUM ONLY PLAN
401k plan membership statisitcs for EMPIRE SCREEN PRINTING INC SECT 125 PREMIUM ONLY PLAN
| Measure | Date | Value |
|---|
| 2022: EMPIRE SCREEN PRINTING INC SECT 125 PREMIUM ONLY PLAN 2022 401k membership |
|---|
| Total participants, beginning-of-year | 2022-07-01 | 222 |
| Total number of active participants reported on line 7a of the Form 5500 | 2022-07-01 | 176 |
| Number of retired or separated participants receiving benefits | 2022-07-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2022-07-01 | 0 |
| Total of all active and inactive participants | 2022-07-01 | 176 |
| 2021: EMPIRE SCREEN PRINTING INC SECT 125 PREMIUM ONLY PLAN 2021 401k membership |
|---|
| Total participants, beginning-of-year | 2021-07-01 | 209 |
| Total number of active participants reported on line 7a of the Form 5500 | 2021-07-01 | 222 |
| Number of retired or separated participants receiving benefits | 2021-07-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2021-07-01 | 0 |
| Total of all active and inactive participants | 2021-07-01 | 222 |
| 2020: EMPIRE SCREEN PRINTING INC SECT 125 PREMIUM ONLY PLAN 2020 401k membership |
|---|
| Total participants, beginning-of-year | 2020-07-01 | 272 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-07-01 | 208 |
| Number of retired or separated participants receiving benefits | 2020-07-01 | 1 |
| Number of other retired or separated participants entitled to future benefits | 2020-07-01 | 0 |
| Total of all active and inactive participants | 2020-07-01 | 209 |
| 2019: EMPIRE SCREEN PRINTING INC SECT 125 PREMIUM ONLY PLAN 2019 401k membership |
|---|
| Total participants, beginning-of-year | 2019-07-01 | 282 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-07-01 | 271 |
| Number of retired or separated participants receiving benefits | 2019-07-01 | 1 |
| Number of other retired or separated participants entitled to future benefits | 2019-07-01 | 0 |
| Total of all active and inactive participants | 2019-07-01 | 272 |
| 2018: EMPIRE SCREEN PRINTING INC SECT 125 PREMIUM ONLY PLAN 2018 401k membership |
|---|
| Total participants, beginning-of-year | 2018-07-01 | 282 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-07-01 | 282 |
| Number of retired or separated participants receiving benefits | 2018-07-01 | 1 |
| Number of other retired or separated participants entitled to future benefits | 2018-07-01 | 0 |
| Total of all active and inactive participants | 2018-07-01 | 283 |
| 2017: EMPIRE SCREEN PRINTING INC SECT 125 PREMIUM ONLY PLAN 2017 401k membership |
|---|
| Total participants, beginning-of-year | 2017-07-01 | 0 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-07-01 | 282 |
| Total of all active and inactive participants | 2017-07-01 | 282 |
| Total participants | 2017-07-01 | 282 |
| 2016: EMPIRE SCREEN PRINTING INC SECT 125 PREMIUM ONLY PLAN 2016 401k membership |
|---|
| Total participants, beginning-of-year | 2016-07-01 | 0 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-07-01 | 278 |
| Number of retired or separated participants receiving benefits | 2016-07-01 | 5 |
| Number of other retired or separated participants entitled to future benefits | 2016-07-01 | 6 |
| Total of all active and inactive participants | 2016-07-01 | 289 |
| Total participants | 2016-07-01 | 289 |
| 2015: EMPIRE SCREEN PRINTING INC SECT 125 PREMIUM ONLY PLAN 2015 401k membership |
|---|
| Total participants, beginning-of-year | 2015-07-01 | 0 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-07-01 | 240 |
| Number of retired or separated participants receiving benefits | 2015-07-01 | 2 |
| Number of other retired or separated participants entitled to future benefits | 2015-07-01 | 2 |
| Total of all active and inactive participants | 2015-07-01 | 244 |
| Total participants | 2015-07-01 | 0 |
| 2014: EMPIRE SCREEN PRINTING INC SECT 125 PREMIUM ONLY PLAN 2014 401k membership |
|---|
| Total participants, beginning-of-year | 2014-07-01 | 229 |
| Total number of active participants reported on line 7a of the Form 5500 | 2014-07-01 | 249 |
| Number of retired or separated participants receiving benefits | 2014-07-01 | 2 |
| Number of other retired or separated participants entitled to future benefits | 2014-07-01 | 1 |
| Total of all active and inactive participants | 2014-07-01 | 252 |
| Total participants | 2014-07-01 | 0 |
| 2013: EMPIRE SCREEN PRINTING INC SECT 125 PREMIUM ONLY PLAN 2013 401k membership |
|---|
| Total participants, beginning-of-year | 2013-07-01 | 237 |
| Total number of active participants reported on line 7a of the Form 5500 | 2013-07-01 | 229 |
| Number of retired or separated participants receiving benefits | 2013-07-01 | 6 |
| Number of other retired or separated participants entitled to future benefits | 2013-07-01 | 1 |
| Total of all active and inactive participants | 2013-07-01 | 236 |
| Total participants | 2013-07-01 | 0 |
| 2012: EMPIRE SCREEN PRINTING INC SECT 125 PREMIUM ONLY PLAN 2012 401k membership |
|---|
| Total participants, beginning-of-year | 2012-07-01 | 246 |
| Total number of active participants reported on line 7a of the Form 5500 | 2012-07-01 | 237 |
| Number of retired or separated participants receiving benefits | 2012-07-01 | 2 |
| Number of other retired or separated participants entitled to future benefits | 2012-07-01 | 2 |
| Total of all active and inactive participants | 2012-07-01 | 241 |
| Total participants | 2012-07-01 | 0 |
| 2011: EMPIRE SCREEN PRINTING INC SECT 125 PREMIUM ONLY PLAN 2011 401k membership |
|---|
| Total participants, beginning-of-year | 2011-07-01 | 253 |
| Total number of active participants reported on line 7a of the Form 5500 | 2011-07-01 | 243 |
| Number of retired or separated participants receiving benefits | 2011-07-01 | 3 |
| Number of other retired or separated participants entitled to future benefits | 2011-07-01 | 0 |
| Total of all active and inactive participants | 2011-07-01 | 246 |
| 2009: EMPIRE SCREEN PRINTING INC SECT 125 PREMIUM ONLY PLAN 2009 401k membership |
|---|
| Total participants, beginning-of-year | 2009-07-01 | 408 |
| Total number of active participants reported on line 7a of the Form 5500 | 2009-07-01 | 220 |
| Number of retired or separated participants receiving benefits | 2009-07-01 | 3 |
| Number of other retired or separated participants entitled to future benefits | 2009-07-01 | 0 |
| Total of all active and inactive participants | 2009-07-01 | 223 |
| 2007: EMPIRE SCREEN PRINTING INC SECT 125 PREMIUM ONLY PLAN 2007 401k membership |
|---|
| Total participants, beginning-of-year | 2007-07-01 | 282 |
| Total number of active participants reported on line 7a of the Form 5500 | 2007-07-01 | 412 |
| Number of retired or separated participants receiving benefits | 2007-07-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2007-07-01 | 0 |
| Total of all active and inactive participants | 2007-07-01 | 412 |
| Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits | 2007-07-01 | 0 |
| Total participants | 2007-07-01 | 412 |
| Number of participants with account balances | 2007-07-01 | 0 |
| Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested | 2007-07-01 | 0 |
| WYSSTA INSURANCE COMPANY INC. (National Association of Insurance Commissioners NAIC id number: 12352 ) |
| Policy contract number | 40555 00000 |
| Policy instance | 2 |
| Insurance contract or identification number | 40555 00000 | | Number of Individuals Covered | 103 | | Insurance policy start date | 2022-10-01 | | Insurance policy end date | 2023-09-30 | | Total amount of commissions paid to insurance broker | USD $887 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $11,083 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $887 | | Insurance broker organization code? | 3 |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 941852 |
| Policy instance | 7 |
| Insurance contract or identification number | 941852 | | Number of Individuals Covered | 125 | | Insurance policy start date | 2022-10-01 | | Insurance policy end date | 2023-09-30 | | Welfare Benefit Premiums Paid to Carrier | USD $249,686 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL OF WISCONSIN (National Association of Insurance Commissioners NAIC id number: 54046 ) |
| Policy contract number | 13112 00000 |
| Policy instance | 1 |
| Insurance contract or identification number | 13112 00000 | | Number of Individuals Covered | 138 | | Insurance policy start date | 2022-10-01 | | Insurance policy end date | 2023-09-30 | | Total amount of commissions paid to insurance broker | USD $6,443 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,443 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG0ANMN |
| Policy instance | 3 |
| Insurance contract or identification number | GLUG0ANMN | | Number of Individuals Covered | 177 | | Insurance policy start date | 2022-10-01 | | Insurance policy end date | 2023-10-01 | | Total amount of commissions paid to insurance broker | USD $1,642 | | Total amount of fees paid to insurance company | USD $780 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | LIFE & AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $10,950 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,642 | | Amount paid for insurance broker fees | 468 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUC0ANMN |
| Policy instance | 4 |
| Insurance contract or identification number | GUC0ANMN | | Number of Individuals Covered | 104 | | Insurance policy start date | 2022-10-01 | | Insurance policy end date | 2023-10-01 | | Total amount of commissions paid to insurance broker | USD $7,362 | | Total amount of fees paid to insurance company | USD $4,005 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $49,080 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,362 | | Amount paid for insurance broker fees | 2403 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUPR0ANMN |
| Policy instance | 5 |
| Insurance contract or identification number | GUPR0ANMN | | Number of Individuals Covered | 75 | | Insurance policy start date | 2022-10-01 | | Insurance policy end date | 2023-10-01 | | Total amount of commissions paid to insurance broker | USD $2,658 | | Total amount of fees paid to insurance company | USD $1,344 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $17,718 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,658 | | Amount paid for insurance broker fees | 806 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GVTL0ANMN |
| Policy instance | 6 |
| Insurance contract or identification number | GVTL0ANMN | | Number of Individuals Covered | 59 | | Insurance policy start date | 2022-10-01 | | Insurance policy end date | 2023-10-01 | | Total amount of commissions paid to insurance broker | USD $3,301 | | Total amount of fees paid to insurance company | USD $1,630 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | LIFE & AD&D VOLUNTARY | | Welfare Benefit Premiums Paid to Carrier | USD $22,003 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,301 | | Amount paid for insurance broker fees | 978 | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL OF WISCONSIN (National Association of Insurance Commissioners NAIC id number: 54046 ) |
| Policy contract number | 13112 00000 |
| Policy instance | 1 |
| Insurance contract or identification number | 13112 00000 | | Number of Individuals Covered | 160 | | Insurance policy start date | 2021-10-01 | | Insurance policy end date | 2022-09-30 | | Total amount of commissions paid to insurance broker | USD $7,632 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,632 | | Insurance broker organization code? | 3 |
|
| WYSSTA INSURANCE COMPANY INC. (National Association of Insurance Commissioners NAIC id number: 12352 ) |
| Policy contract number | 40555 00000 |
| Policy instance | 2 |
| Insurance contract or identification number | 40555 00000 | | Number of Individuals Covered | 122 | | Insurance policy start date | 2020-10-01 | | Insurance policy end date | 2022-09-30 | | Total amount of commissions paid to insurance broker | USD $952 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $13,022 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $952 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG0ANMN |
| Policy instance | 3 |
| Insurance contract or identification number | GLUG0ANMN | | Number of Individuals Covered | 213 | | Insurance policy start date | 2021-10-01 | | Insurance policy end date | 2022-10-01 | | Total amount of commissions paid to insurance broker | USD $1,507 | | Total amount of fees paid to insurance company | USD $772 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | LIFE & AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $10,047 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,507 | | Amount paid for insurance broker fees | 463 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GVTL0ANMN |
| Policy instance | 6 |
| Insurance contract or identification number | GVTL0ANMN | | Number of Individuals Covered | 66 | | Insurance policy start date | 2021-10-01 | | Insurance policy end date | 2022-10-01 | | Total amount of commissions paid to insurance broker | USD $3,288 | | Total amount of fees paid to insurance company | USD $1,657 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | LIFE & AD&D VOLUNTARY | | Welfare Benefit Premiums Paid to Carrier | USD $21,922 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,288 | | Amount paid for insurance broker fees | 994 | | Insurance broker organization code? | 3 |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 941852 |
| Policy instance | 7 |
| Insurance contract or identification number | 941852 | | Number of Individuals Covered | 135 | | Insurance policy start date | 2021-10-01 | | Insurance policy end date | 2022-09-30 | | Welfare Benefit Premiums Paid to Carrier | USD $279,247 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUC0ANMN |
| Policy instance | 4 |
| Insurance contract or identification number | GUC0ANMN | | Number of Individuals Covered | 125 | | Insurance policy start date | 2021-10-01 | | Insurance policy end date | 2022-10-01 | | Total amount of commissions paid to insurance broker | USD $8,147 | | Total amount of fees paid to insurance company | USD $4,254 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $54,311 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,147 | | Amount paid for insurance broker fees | 2552 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUPR0ANMN |
| Policy instance | 5 |
| Insurance contract or identification number | GUPR0ANMN | | Number of Individuals Covered | 90 | | Insurance policy start date | 2021-10-01 | | Insurance policy end date | 2022-10-01 | | Total amount of commissions paid to insurance broker | USD $2,682 | | Total amount of fees paid to insurance company | USD $1,332 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $17,881 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,682 | | Amount paid for insurance broker fees | 799 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUPR0ANMN |
| Policy instance | 5 |
| Insurance contract or identification number | GUPR0ANMN | | Number of Individuals Covered | 89 | | Insurance policy start date | 2020-07-01 | | Insurance policy end date | 2021-10-01 | | Total amount of commissions paid to insurance broker | USD $3,129 | | Total amount of fees paid to insurance company | USD $677 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $20,861 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,129 | | Amount paid for insurance broker fees | 677 | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL OF WISCONSIN (National Association of Insurance Commissioners NAIC id number: 54046 ) |
| Policy contract number | 13112 00000 |
| Policy instance | 1 |
| Insurance contract or identification number | 13112 00000 | | Number of Individuals Covered | 160 | | Insurance policy start date | 2020-10-01 | | Insurance policy end date | 2021-09-30 | | Total amount of commissions paid to insurance broker | USD $7,796 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,796 | | Insurance broker organization code? | 3 |
|
| WYSSTA INSURANCE COMPANY INC. (National Association of Insurance Commissioners NAIC id number: 12352 ) |
| Policy contract number | 40555 00000 |
| Policy instance | 2 |
| Insurance contract or identification number | 40555 00000 | | Number of Individuals Covered | 128 | | Insurance policy start date | 2020-10-01 | | Insurance policy end date | 2022-09-30 | | Total amount of commissions paid to insurance broker | USD $1,095 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $13,535 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,095 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG0ANMN |
| Policy instance | 3 |
| Insurance contract or identification number | GLUG0ANMN | | Number of Individuals Covered | 218 | | Insurance policy start date | 2020-07-01 | | Insurance policy end date | 2021-10-01 | | Total amount of commissions paid to insurance broker | USD $1,961 | | Total amount of fees paid to insurance company | USD $475 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | LIFE & AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $13,074 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,961 | | Amount paid for insurance broker fees | 475 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUC0ANMN |
| Policy instance | 4 |
| Insurance contract or identification number | GUC0ANMN | | Number of Individuals Covered | 136 | | Insurance policy start date | 2020-07-01 | | Insurance policy end date | 2021-10-01 | | Total amount of commissions paid to insurance broker | USD $10,341 | | Total amount of fees paid to insurance company | USD $2,217 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $68,938 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $10,341 | | Amount paid for insurance broker fees | 2217 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GVTL0ANMN |
| Policy instance | 6 |
| Insurance contract or identification number | GVTL0ANMN | | Number of Individuals Covered | 72 | | Insurance policy start date | 2020-07-01 | | Insurance policy end date | 2020-10-01 | | Total amount of commissions paid to insurance broker | USD $3,988 | | Total amount of fees paid to insurance company | USD $928 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | LIFE & AD&D VOLUNTARY | | Welfare Benefit Premiums Paid to Carrier | USD $26,586 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,988 | | Amount paid for insurance broker fees | 928 | | Insurance broker organization code? | 3 |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 941852 |
| Policy instance | 7 |
| Insurance contract or identification number | 941852 | | Number of Individuals Covered | 129 | | Insurance policy start date | 2020-10-01 | | Insurance policy end date | 2021-09-30 | | Welfare Benefit Premiums Paid to Carrier | USD $253,277 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Insurance broker organization code? | 3 |
|
| UNITY HEALTH PLANS INSURANCE CORPORATION (National Association of Insurance Commissioners NAIC id number: 95796 ) |
| Policy contract number | 904956 |
| Policy instance | 8 |
| Insurance contract or identification number | 904956 | | Number of Individuals Covered | 145 | | Insurance policy start date | 2020-07-01 | | Insurance policy end date | 2020-09-30 | | Total amount of commissions paid to insurance broker | USD $6,414 | | Welfare Benefit Premiums Paid to Carrier | USD $122,367 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,414 | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL OF WISCONSIN (National Association of Insurance Commissioners NAIC id number: 54046 ) |
| Policy contract number | 13112 00000 |
| Policy instance | 1 |
| Insurance contract or identification number | 13112 00000 | | Number of Individuals Covered | 181 | | Insurance policy start date | 2019-10-01 | | Insurance policy end date | 2020-09-30 | | Total amount of commissions paid to insurance broker | USD $8,143 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,143 | | Insurance broker organization code? | 3 |
|
| WYSSTA INSURANCE COMPANY INC. (National Association of Insurance Commissioners NAIC id number: 12352 ) |
| Policy contract number | 40555 00000 |
| Policy instance | 2 |
| Insurance contract or identification number | 40555 00000 | | Number of Individuals Covered | 114 | | Insurance policy start date | 2018-10-01 | | Insurance policy end date | 2022-09-30 | | Total amount of commissions paid to insurance broker | USD $980 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $11,648 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $980 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG0ANMN |
| Policy instance | 3 |
| Insurance contract or identification number | GLUG0ANMN | | Number of Individuals Covered | 222 | | Insurance policy start date | 2019-07-01 | | Insurance policy end date | 2020-07-01 | | Total amount of commissions paid to insurance broker | USD $1,635 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | LIFE & AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $10,898 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,635 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUC0ANMN |
| Policy instance | 4 |
| Insurance contract or identification number | GUC0ANMN | | Number of Individuals Covered | 144 | | Insurance policy start date | 2019-07-01 | | Insurance policy end date | 2020-07-01 | | Total amount of commissions paid to insurance broker | USD $6,656 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $44,374 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,656 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GVTL0ANMN |
| Policy instance | 6 |
| Insurance contract or identification number | GVTL0ANMN | | Number of Individuals Covered | 62 | | Insurance policy start date | 2019-07-01 | | Insurance policy end date | 2020-07-01 | | Total amount of commissions paid to insurance broker | USD $3,022 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | LIFE & AD&D VOLUNTARY | | Welfare Benefit Premiums Paid to Carrier | USD $20,146 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,022 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUPR0ANMN |
| Policy instance | 5 |
| Insurance contract or identification number | GUPR0ANMN | | Number of Individuals Covered | 91 | | Insurance policy start date | 2019-07-01 | | Insurance policy end date | 2020-07-01 | | Total amount of commissions paid to insurance broker | USD $2,222 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $14,813 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,222 | | Insurance broker organization code? | 3 |
|
| HEALTH TRADITION (National Association of Insurance Commissioners NAIC id number: 96628 ) |
| Policy contract number | 65008 |
| Policy instance | 7 |
| Insurance contract or identification number | 65008 | | Number of Individuals Covered | 134 | | Insurance policy start date | 2019-07-01 | | Insurance policy end date | 2019-09-30 | | Total amount of commissions paid to insurance broker | USD $2,956 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $208,353 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,956 | | Insurance broker organization code? | 3 |
|
| UNITY HEALTH PLANS INSURANCE CORPORATION (National Association of Insurance Commissioners NAIC id number: 95796 ) |
| Policy contract number | 904956 |
| Policy instance | 8 |
| Insurance contract or identification number | 904956 | | Number of Individuals Covered | 150 | | Insurance policy start date | 2019-10-01 | | Insurance policy end date | 2020-06-30 | | Total amount of commissions paid to insurance broker | USD $17,434 | | Welfare Benefit Premiums Paid to Carrier | USD $610,433 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $17,434 | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL OF WISCONSIN (National Association of Insurance Commissioners NAIC id number: 54046 ) |
| Policy contract number | 13112 00000 |
| Policy instance | 1 |
| Insurance contract or identification number | 13112 00000 | | Number of Individuals Covered | 185 | | Insurance policy start date | 2018-10-01 | | Insurance policy end date | 2019-09-30 | | Total amount of commissions paid to insurance broker | USD $9,111 | | Total amount of fees paid to insurance company | USD $9,374 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $9,111 | | Amount paid for insurance broker fees | 9374 | | Insurance broker organization code? | 3 |
|
| WYSSTA INSURANCE COMPANY INC. (National Association of Insurance Commissioners NAIC id number: 12352 ) |
| Policy contract number | 40555 00000 |
| Policy instance | 2 |
| Insurance contract or identification number | 40555 00000 | | Number of Individuals Covered | 114 | | Insurance policy start date | 2018-10-01 | | Insurance policy end date | 2022-09-30 | | Total amount of commissions paid to insurance broker | USD $1,065 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $12,337 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,065 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG0ANMN |
| Policy instance | 3 |
| Insurance contract or identification number | GLUG0ANMN | | Number of Individuals Covered | 248 | | Insurance policy start date | 2018-07-01 | | Insurance policy end date | 2019-07-01 | | Total amount of commissions paid to insurance broker | USD $1,790 | | Total amount of fees paid to insurance company | USD $562 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | LIFE & AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $11,931 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,790 | | Amount paid for insurance broker fees | 562 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUC0ANMN |
| Policy instance | 4 |
| Insurance contract or identification number | GUC0ANMN | | Number of Individuals Covered | 164 | | Insurance policy start date | 2018-07-01 | | Insurance policy end date | 2019-07-01 | | Total amount of commissions paid to insurance broker | USD $6,551 | | Total amount of fees paid to insurance company | USD $2,113 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $43,674 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,551 | | Amount paid for insurance broker fees | 2113 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUPR0ANMN |
| Policy instance | 5 |
| Insurance contract or identification number | GUPR0ANMN | | Number of Individuals Covered | 101 | | Insurance policy start date | 2018-07-01 | | Insurance policy end date | 2019-07-01 | | Total amount of commissions paid to insurance broker | USD $2,411 | | Total amount of fees paid to insurance company | USD $855 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $16,074 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,411 | | Amount paid for insurance broker fees | 855 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GVTL0ANMN |
| Policy instance | 6 |
| Insurance contract or identification number | GVTL0ANMN | | Number of Individuals Covered | 71 | | Insurance policy start date | 2018-07-01 | | Insurance policy end date | 2019-07-01 | | Total amount of commissions paid to insurance broker | USD $3,034 | | Total amount of fees paid to insurance company | USD $1,006 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | LIFE & AD&D VOLUNTARY | | Welfare Benefit Premiums Paid to Carrier | USD $20,227 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,034 | | Amount paid for insurance broker fees | 1006 | | Insurance broker organization code? | 3 |
|
| HEALTH TRADITION (National Association of Insurance Commissioners NAIC id number: 96628 ) |
| Policy contract number | 65008 |
| Policy instance | 7 |
| Insurance contract or identification number | 65008 | | Number of Individuals Covered | 161 | | Insurance policy start date | 2018-07-01 | | Insurance policy end date | 2019-06-30 | | Total amount of commissions paid to insurance broker | USD $19,172 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $818,006 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $19,172 | | Insurance broker organization code? | 3 |
|
| WYSSTA INSURANCE COMPANY INC. (National Association of Insurance Commissioners NAIC id number: 12352 ) |
| Policy contract number | 40555 |
| Policy instance | 2 |
| Insurance contract or identification number | 40555 | | Number of Individuals Covered | 98 | | Insurance policy start date | 2016-10-01 | | Insurance policy end date | 2018-09-30 | | Total amount of commissions paid to insurance broker | USD $800 | | Total amount of fees paid to insurance company | USD $800 | | Vision Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $800 | | Amount paid for insurance broker fees | 800 | | Insurance broker organization code? | 3 | | Insurance broker name | THE INSURANCE CENTER |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG0ANMN |
| Policy instance | 3 |
| Insurance contract or identification number | GLUG0ANMN | | Number of Individuals Covered | 241 | | Insurance policy start date | 2017-07-01 | | Insurance policy end date | 2018-07-01 | | Total amount of commissions paid to insurance broker | USD $1,523 | | Total amount of fees paid to insurance company | USD $243 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | LIFE & AD&D | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,523 | | Amount paid for insurance broker fees | 243 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | TIC INC |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUPR0ANMN |
| Policy instance | 5 |
| Insurance contract or identification number | GUPR0ANMN | | Number of Individuals Covered | 110 | | Insurance policy start date | 2017-07-01 | | Insurance policy end date | 2018-07-01 | | Total amount of commissions paid to insurance broker | USD $2,742 | | Total amount of fees paid to insurance company | USD $468 | | Long Term Disability Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,742 | | Amount paid for insurance broker fees | 468 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | TIC INC |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUC0ANMN |
| Policy instance | 4 |
| Insurance contract or identification number | GUC0ANMN | | Number of Individuals Covered | 159 | | Insurance policy start date | 2017-07-01 | | Insurance policy end date | 2018-07-01 | | Total amount of commissions paid to insurance broker | USD $6,287 | | Total amount of fees paid to insurance company | USD $1,063 | | Temporary Disability Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,287 | | Amount paid for insurance broker fees | 1063 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | TIC INC |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GVTL0ANMN |
| Policy instance | 6 |
| Insurance contract or identification number | GVTL0ANMN | | Number of Individuals Covered | 73 | | Insurance policy start date | 2017-07-01 | | Insurance policy end date | 2018-07-01 | | Total amount of commissions paid to insurance broker | USD $3,028 | | Total amount of fees paid to insurance company | USD $495 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | LIFE & AD&D - VOLUNTARY | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,028 | | Amount paid for insurance broker fees | 495 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | TIC INC |
|
| HEALTH TRADITION (National Association of Insurance Commissioners NAIC id number: 96628 ) |
| Policy contract number | L327 |
| Policy instance | 7 |
| Insurance contract or identification number | L327 | | Number of Individuals Covered | 152 | | Insurance policy start date | 2017-07-01 | | Insurance policy end date | 2018-06-30 | | Total amount of commissions paid to insurance broker | USD $16,932 | | Health Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $16,932 | | Insurance broker organization code? | 3 | | Insurance broker name | TIC INC. |
|
| HEALTH TRADITION (National Association of Insurance Commissioners NAIC id number: 96628 ) |
| Policy contract number | LC206 |
| Policy instance | 8 |
| Insurance contract or identification number | LC206 | | Number of Individuals Covered | 4 | | Insurance policy start date | 2017-07-01 | | Insurance policy end date | 2018-06-30 | | Total amount of commissions paid to insurance broker | USD $480 | | Health Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $480 | | Insurance broker organization code? | 3 | | Insurance broker name | TIC INC |
|
| DELTA DENTAL OF WISCONSIN (National Association of Insurance Commissioners NAIC id number: 54046 ) |
| Policy contract number | 13112 |
| Policy instance | 1 |
| Insurance contract or identification number | 13112 | | Number of Individuals Covered | 165 | | Insurance policy start date | 2017-10-01 | | Insurance policy end date | 2018-09-30 | | Total amount of commissions paid to insurance broker | USD $7,017 | | Total amount of fees paid to insurance company | USD $9,213 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,017 | | Amount paid for insurance broker fees | 9213 | | Insurance broker organization code? | 3 | | Insurance broker name | THE INSURANCE CENTER |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GVTL0ANMN |
| Policy instance | 6 |
| Insurance contract or identification number | GVTL0ANMN | | Number of Individuals Covered | 84 | | Insurance policy start date | 2015-07-01 | | Insurance policy end date | 2016-07-01 | | Total amount of commissions paid to insurance broker | USD $2,729 | | Total amount of fees paid to insurance company | USD $768 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $18,191 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,729 | | Amount paid for insurance broker fees | 768 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | TIC INC |
|
| DELTA DENTAL OF WISCONSIN (National Association of Insurance Commissioners NAIC id number: 54046 ) |
| Policy contract number | 13112 |
| Policy instance | 1 |
| Insurance contract or identification number | 13112 | | Number of Individuals Covered | 169 | | Insurance policy start date | 2015-10-01 | | Insurance policy end date | 2016-09-30 | | Total amount of commissions paid to insurance broker | USD $8,454 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $85,115 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,454 | | Insurance broker organization code? | 3 | | Insurance broker name | TIC INC |
|
| WYSSTA INSURANCE COMPANY INC. (National Association of Insurance Commissioners NAIC id number: 12352 ) |
| Policy contract number | 40555 |
| Policy instance | 2 |
| Insurance contract or identification number | 40555 | | Number of Individuals Covered | 96 | | Insurance policy start date | 2014-10-01 | | Insurance policy end date | 2016-09-30 | | Total amount of commissions paid to insurance broker | USD $901 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $10,392 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $901 | | Insurance broker organization code? | 3 | | Insurance broker name | TIC INC |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG0ANMN |
| Policy instance | 3 |
| Insurance contract or identification number | GLUG0ANMN | | Number of Individuals Covered | 246 | | Insurance policy start date | 2015-07-01 | | Insurance policy end date | 2016-07-01 | | Total amount of commissions paid to insurance broker | USD $1,442 | | Total amount of fees paid to insurance company | USD $397 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $9,614 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,442 | | Amount paid for insurance broker fees | 397 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | TIC INC |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUC0ANMN |
| Policy instance | 4 |
| Insurance contract or identification number | GUC0ANMN | | Number of Individuals Covered | 161 | | Insurance policy start date | 2015-07-01 | | Insurance policy end date | 2016-07-01 | | Total amount of commissions paid to insurance broker | USD $6,505 | | Total amount of fees paid to insurance company | USD $1,833 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $43,365 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,505 | | Amount paid for insurance broker fees | 1833 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | TIC INC |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUPR0ANMN |
| Policy instance | 5 |
| Insurance contract or identification number | GUPR0ANMN | | Number of Individuals Covered | 126 | | Insurance policy start date | 2015-07-01 | | Insurance policy end date | 2016-07-01 | | Total amount of commissions paid to insurance broker | USD $2,336 | | Total amount of fees paid to insurance company | USD $621 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $15,572 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,336 | | Amount paid for insurance broker fees | 621 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | TIC INC. |
|
| HEALTH TRADITION (National Association of Insurance Commissioners NAIC id number: 96628 ) |
| Policy contract number | L327 |
| Policy instance | 7 |
| Insurance contract or identification number | L327 | | Number of Individuals Covered | 149 | | Insurance policy start date | 2015-07-01 | | Insurance policy end date | 2016-06-30 | | Total amount of commissions paid to insurance broker | USD $16,698 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $717,472 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $16,698 | | Insurance broker organization code? | 3 | | Insurance broker name | THE INSURANCE CENTER |
|
| HEALTH TRADITION (National Association of Insurance Commissioners NAIC id number: 96628 ) |
| Policy contract number | LC206 |
| Policy instance | 8 |
| Insurance contract or identification number | LC206 | | Number of Individuals Covered | 7 | | Insurance policy start date | 2015-07-01 | | Insurance policy end date | 2016-06-30 | | Total amount of commissions paid to insurance broker | USD $732 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $38,847 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $732 | | Insurance broker organization code? | 3 | | Insurance broker name | THE INSURANCE CENTER |
|
| HEALTH TRADITION (National Association of Insurance Commissioners NAIC id number: 96628 ) |
| Policy contract number | L244 |
| Policy instance | 1 |
| Insurance contract or identification number | L244 | | Number of Individuals Covered | 122 | | Insurance policy start date | 2014-07-01 | | Insurance policy end date | 2014-09-30 | | Total amount of commissions paid to insurance broker | USD $3,771 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $106,565 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,771 | | Insurance broker organization code? | 3 | | Insurance broker name | THE INSURANCE CENTER |
|
| DELTA DENTAL OF WISCONSIN (National Association of Insurance Commissioners NAIC id number: 54046 ) |
| Policy contract number | 13112 |
| Policy instance | 3 |
| Insurance contract or identification number | 13112 | | Number of Individuals Covered | 171 | | Insurance policy start date | 2014-10-01 | | Insurance policy end date | 2015-09-30 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Insurance broker organization code? | 3 | | Insurance broker name | TIC INC |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUC0ANMN |
| Policy instance | 6 |
| Insurance contract or identification number | GUC0ANMN | | Number of Individuals Covered | 156 | | Insurance policy start date | 2014-07-01 | | Insurance policy end date | 2015-07-01 | | Total amount of commissions paid to insurance broker | USD $5,604 | | Total amount of fees paid to insurance company | USD $1,808 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $37,357 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,604 | | Amount paid for insurance broker fees | 1808 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | T.I.C. INC |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUPR0ANMN |
| Policy instance | 7 |
| Insurance contract or identification number | GUPR0ANMN | | Number of Individuals Covered | 133 | | Insurance policy start date | 2014-07-01 | | Insurance policy end date | 2015-07-01 | | Total amount of commissions paid to insurance broker | USD $2,252 | | Total amount of fees paid to insurance company | USD $816 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $15,011 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,252 | | Amount paid for insurance broker fees | 816 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | TIC INC. |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GVTLOANMN |
| Policy instance | 8 |
| Insurance contract or identification number | GVTLOANMN | | Number of Individuals Covered | 83 | | Insurance policy start date | 2014-07-01 | | Insurance policy end date | 2015-07-01 | | Total amount of commissions paid to insurance broker | USD $2,570 | | Total amount of fees paid to insurance company | USD $884 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $17,132 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,570 | | Amount paid for insurance broker fees | 884 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | TIC INC |
|
| HEALTH TRADITION (National Association of Insurance Commissioners NAIC id number: 96628 ) |
| Policy contract number | L327 |
| Policy instance | 9 |
| Insurance contract or identification number | L327 | | Number of Individuals Covered | 149 | | Insurance policy start date | 2014-10-01 | | Insurance policy end date | 2015-06-30 | | Total amount of commissions paid to insurance broker | USD $12,150 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $441,548 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $12,150 | | Insurance broker organization code? | 3 | | Insurance broker name | THE INSURANCE CENTER |
|
| HEALTH TRADITION (National Association of Insurance Commissioners NAIC id number: 96628 ) |
| Policy contract number | LC206 |
| Policy instance | 10 |
| Insurance contract or identification number | LC206 | | Number of Individuals Covered | 7 | | Insurance policy start date | 2014-10-01 | | Insurance policy end date | 2015-06-30 | | Total amount of commissions paid to insurance broker | USD $630 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $27,255 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $630 | | Insurance broker organization code? | 3 | | Insurance broker name | THE INSURANCE CENTER |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG0ANMN |
| Policy instance | 5 |
| Insurance contract or identification number | GLUG0ANMN | | Number of Individuals Covered | 253 | | Insurance policy start date | 2014-07-01 | | Insurance policy end date | 2015-07-01 | | Total amount of commissions paid to insurance broker | USD $1,273 | | Total amount of fees paid to insurance company | USD $423 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $8,488 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,273 | | Amount paid for insurance broker fees | 423 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | T.I.C. INC |
|
| HEALTH TRADITION (National Association of Insurance Commissioners NAIC id number: 96628 ) |
| Policy contract number | LC203 |
| Policy instance | 2 |
| Insurance contract or identification number | LC203 | | Number of Individuals Covered | 7 | | Insurance policy start date | 2014-07-01 | | Insurance policy end date | 2014-09-30 | | Total amount of commissions paid to insurance broker | USD $321 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $12,287 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $321 | | Insurance broker organization code? | 3 | | Insurance broker name | THE INSURANCE CENTER |
|
| WYSSTA INSURANCE COMPANY INC. (National Association of Insurance Commissioners NAIC id number: 12352 ) |
| Policy contract number | 40555 |
| Policy instance | 4 |
| Insurance contract or identification number | 40555 | | Number of Individuals Covered | 90 | | Insurance policy start date | 2014-10-01 | | Insurance policy end date | 2016-09-30 | | Total amount of commissions paid to insurance broker | USD $752 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $9,400 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $752 | | Insurance broker organization code? | 3 | | Insurance broker name | TIC INC |
|
| HEALTH TRADITION (National Association of Insurance Commissioners NAIC id number: 96628 ) |
| Policy contract number | LC203 |
| Policy instance | 2 |
| Insurance contract or identification number | LC203 | | Number of Individuals Covered | 10 | | Insurance policy start date | 2013-07-01 | | Insurance policy end date | 2014-06-30 | | Total amount of fees paid to insurance company | USD $1,374 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $38,266 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 1374 | | Insurance broker organization code? | 3 | | Insurance broker name | THE INSURANCE CENTER |
|
| DELTA DENTAL OF WISCONSIN (National Association of Insurance Commissioners NAIC id number: 54046 ) |
| Policy contract number | 13112 |
| Policy instance | 3 |
| Insurance contract or identification number | 13112 | | Number of Individuals Covered | 149 | | Insurance policy start date | 2014-10-01 | | Insurance policy end date | 2015-09-30 | | Total amount of commissions paid to insurance broker | USD $7,262 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,262 | | Insurance broker organization code? | 3 | | Insurance broker name | T.I.C. INC |
|
| WYSSTA INSURANCE COMPANY INC. (National Association of Insurance Commissioners NAIC id number: 12352 ) |
| Policy contract number | 40555 |
| Policy instance | 4 |
| Insurance contract or identification number | 40555 | | Number of Individuals Covered | 81 | | Insurance policy start date | 2014-10-01 | | Insurance policy end date | 2016-09-30 | | Total amount of commissions paid to insurance broker | USD $783 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $9,793 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $783 | | Insurance broker organization code? | 3 | | Insurance broker name | T.I.C. INC |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUCOANMN |
| Policy instance | 6 |
| Insurance contract or identification number | GUCOANMN | | Number of Individuals Covered | 87 | | Insurance policy start date | 2013-07-01 | | Insurance policy end date | 2014-07-01 | | Total amount of commissions paid to insurance broker | USD $2,574 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $17,161 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,574 | | Insurance broker organization code? | 3 | | Insurance broker name | TIC INC |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUGOANMN |
| Policy instance | 5 |
| Insurance contract or identification number | GLUGOANMN | | Number of Individuals Covered | 230 | | Insurance policy start date | 2013-07-01 | | Insurance policy end date | 2014-07-01 | | Total amount of commissions paid to insurance broker | USD $1,243 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $8,286 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,243 | | Insurance broker organization code? | 3 | | Insurance broker name | TIC INC |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUPROANMN |
| Policy instance | 7 |
| Insurance contract or identification number | GUPROANMN | | Number of Individuals Covered | 159 | | Insurance policy start date | 2013-07-01 | | Insurance policy end date | 2014-07-01 | | Total amount of commissions paid to insurance broker | USD $5,382 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $35,880 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,382 | | Insurance broker organization code? | 3 | | Insurance broker name | TIC INC |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GVTLOANMN |
| Policy instance | 8 |
| Insurance contract or identification number | GVTLOANMN | | Number of Individuals Covered | 154 | | Insurance policy start date | 2013-07-01 | | Insurance policy end date | 2014-07-01 | | Total amount of commissions paid to insurance broker | USD $2,471 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $16,476 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,471 | | Insurance broker organization code? | 3 | | Insurance broker name | TIC INC |
|
| HEALTH TRADITION (National Association of Insurance Commissioners NAIC id number: 96628 ) |
| Policy contract number | L244 |
| Policy instance | 1 |
| Insurance contract or identification number | L244 | | Number of Individuals Covered | 125 | | Insurance policy start date | 2013-07-01 | | Insurance policy end date | 2014-06-30 | | Total amount of commissions paid to insurance broker | USD $14,919 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $402,697 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $14,919 | | Insurance broker organization code? | 3 | | Insurance broker name | THE INSURANCE CENTER |
|
| HEALTH TRADITION (National Association of Insurance Commissioners NAIC id number: 96628 ) |
| Policy contract number | LC203 |
| Policy instance | 12 |
| Insurance contract or identification number | LC203 | | Number of Individuals Covered | 12 | | Insurance policy start date | 2012-07-01 | | Insurance policy end date | 2013-06-30 | | Total amount of commissions paid to insurance broker | USD $1,866 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $42,644 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,866 | | Insurance broker organization code? | 3 | | Insurance broker name | THE INSURANCE CENTER |
|
| THE EPIC LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64149 ) |
| Policy contract number | 161640 |
| Policy instance | 11 |
| Insurance contract or identification number | 161640 | | Number of Individuals Covered | 245 | | Insurance policy start date | 2012-07-01 | | Insurance policy end date | 2012-09-30 | | Total amount of commissions paid to insurance broker | USD $2,140 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $16,137 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,140 | | Insurance broker organization code? | 3 | | Insurance broker name | THE INSURANCE CENTER INC |
|
| AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 ) |
| Policy contract number | 010-027623 |
| Policy instance | 10 |
| Insurance contract or identification number | 010-027623 | | Number of Individuals Covered | 347 | | Insurance policy start date | 2012-07-01 | | Insurance policy end date | 2012-09-30 | | Total amount of commissions paid to insurance broker | USD $1,518 | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Other welfare benefits provided | HEARING | | Welfare Benefit Premiums Paid to Carrier | USD $21,685 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,518 | | Insurance broker organization code? | 3 | | Insurance broker name | THE INSURANCE CENTER INC |
|
| WYSSTA INSURANCE COMPANY INC. (National Association of Insurance Commissioners NAIC id number: 12352 ) |
| Policy contract number | 40555 |
| Policy instance | 8 |
| Insurance contract or identification number | 40555 | | Number of Individuals Covered | 86 | | Insurance policy start date | 2012-10-01 | | Insurance policy end date | 2014-09-30 | | Total amount of commissions paid to insurance broker | USD $585 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $7,315 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $585 | | Insurance broker organization code? | 3 | | Insurance broker name | T.I.C. INC |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000ANMN |
| Policy instance | 4 |
| Insurance contract or identification number | G000ANMN | | Number of Individuals Covered | 240 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-07-01 | | Total amount of commissions paid to insurance broker | USD $639 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $4,258 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $639 | | Insurance broker organization code? | 3 | | Insurance broker name | TIC INC |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000ANMN |
| Policy instance | 3 |
| Insurance contract or identification number | G000ANMN | | Number of Individuals Covered | 90 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-07-01 | | Total amount of commissions paid to insurance broker | USD $1,244 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $8,290 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,244 | | Insurance broker organization code? | 3 | | Insurance broker name | TIC INC |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000ANMN |
| Policy instance | 2 |
| Insurance contract or identification number | G000ANMN | | Number of Individuals Covered | 172 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-07-01 | | Total amount of commissions paid to insurance broker | USD $2,899 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $19,328 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,899 | | Insurance broker organization code? | 3 | | Insurance broker name | TIC INC |
|
| HEALTH TRADITION (National Association of Insurance Commissioners NAIC id number: 96628 ) |
| Policy contract number | L244 |
| Policy instance | 13 |
| Insurance contract or identification number | L244 | | Number of Individuals Covered | 114 | | Insurance policy start date | 2012-07-01 | | Insurance policy end date | 2013-06-30 | | Total amount of commissions paid to insurance broker | USD $14,709 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $301,011 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $14,709 | | Insurance broker organization code? | 3 | | Insurance broker name | THE INSURANCE CENTER |
|
| DELTA DENTAL OF WISCONSIN (National Association of Insurance Commissioners NAIC id number: 54046 ) |
| Policy contract number | 13112 |
| Policy instance | 9 |
| Insurance contract or identification number | 13112 | | Number of Individuals Covered | 156 | | Insurance policy start date | 2012-10-01 | | Insurance policy end date | 2013-09-30 | | Total amount of commissions paid to insurance broker | USD $5,026 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,026 | | Insurance broker organization code? | 3 | | Insurance broker name | T.I.C. INC |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000ANMN |
| Policy instance | 1 |
| Insurance contract or identification number | G000ANMN | | Number of Individuals Covered | 164 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-07-01 | | Total amount of commissions paid to insurance broker | USD $1,318 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $8,784 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,318 | | Insurance broker organization code? | 3 | | Insurance broker name | TIC INC |
|
| GUNDERSEN LUTHERAN HEALTH PLAN, INC. (National Association of Insurance Commissioners NAIC id number: 95101 ) |
| Policy contract number | 614 |
| Policy instance | 3 |
| Insurance contract or identification number | 614 | | Number of Individuals Covered | 97 | | Insurance policy start date | 2011-07-01 | | Insurance policy end date | 2011-09-30 | | Total amount of commissions paid to insurance broker | USD $3,869 | | Total amount of fees paid to insurance company | USD $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 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 | 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 $96,293 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HEALTH TRADITION (National Association of Insurance Commissioners NAIC id number: 96628 ) |
| Policy contract number | LC203 |
| Policy instance | 4 |
| Insurance contract or identification number | LC203 | | Number of Individuals Covered | 17 | | Insurance policy start date | 2011-10-01 | | Insurance policy end date | 2012-06-30 | | Total amount of commissions paid to insurance broker | USD $1,899 | | Total amount of fees paid to insurance company | USD $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 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 $42,265 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HEALTH TRADITION (National Association of Insurance Commissioners NAIC id number: 96628 ) |
| Policy contract number | L244 |
| Policy instance | 5 |
| Insurance contract or identification number | L244 | | Number of Individuals Covered | 115 | | Insurance policy start date | 2011-10-01 | | Insurance policy end date | 2012-06-30 | | Total amount of commissions paid to insurance broker | USD $10,863 | | Total amount of fees paid to insurance company | USD $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 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 $233,157 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 ) |
| Policy contract number | 010-027623 |
| Policy instance | 1 |
| Insurance contract or identification number | 010-027623 | | Number of Individuals Covered | 354 | | Insurance policy start date | 2011-07-01 | | Insurance policy end date | 2012-06-30 | | Total amount of commissions paid to insurance broker | USD $6,778 | | Total amount of fees paid to insurance company | USD $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 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 | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | HEARING | | 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 $96,829 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| THE EPIC LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64149 ) |
| Policy contract number | 161640 |
| Policy instance | 2 |
| Insurance contract or identification number | 161640 | | Number of Individuals Covered | 250 | | Insurance policy start date | 2011-07-01 | | Insurance policy end date | 2012-06-30 | | Total amount of commissions paid to insurance broker | USD $9,421 | | Total amount of fees paid to insurance company | USD $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 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 $73,445 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| GUNDERSEN LUTHERAN HEALTH PLAN, INC. (National Association of Insurance Commissioners NAIC id number: 95101 ) |
| Policy contract number | 614 |
| Policy instance | 3 |
| Insurance contract or identification number | 614 | | Number of Individuals Covered | 139 | | Insurance policy start date | 2010-07-01 | | Insurance policy end date | 2010-12-31 | | Total amount of commissions paid to insurance broker | USD $8,315 | | Total amount of fees paid to insurance company | USD $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 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 | 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 $181,482 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 ) |
| Policy contract number | 20694 |
| Policy instance | 1 |
| Insurance contract or identification number | 20694 | | Number of Individuals Covered | 407 | | Insurance policy start date | 2010-07-01 | | Insurance policy end date | 2011-06-30 | | Total amount of commissions paid to insurance broker | USD $7,252 | | Total amount of fees paid to insurance company | USD $963 | | 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 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 | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | HEARING | | 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 $103,599 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| GUNDERSEN LUTHERAN HEALTH PLAN, INC. (National Association of Insurance Commissioners NAIC id number: 95101 ) |
| Policy contract number | 614 |
| Policy instance | 4 |
| Insurance contract or identification number | 614 | | Number of Individuals Covered | 0 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2011-06-30 | | Total amount of commissions paid to insurance broker | USD $4,441 | | Total amount of fees paid to insurance company | USD $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 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 | 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 $194,126 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| THE EPIC LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64149 ) |
| Policy contract number | 161640 |
| Policy instance | 2 |
| Insurance contract or identification number | 161640 | | Number of Individuals Covered | 218 | | Insurance policy start date | 2010-07-01 | | Insurance policy end date | 2011-06-30 | | Total amount of commissions paid to insurance broker | USD $7,825 | | Total amount of fees paid to insurance company | USD $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 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 $62,498 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
