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EVENTIDE LUTHERAN HOME EMPLOYEE BENEFIT PLAN AND TRUST 401k Plan overview

Plan NameEVENTIDE LUTHERAN HOME EMPLOYEE BENEFIT PLAN AND TRUST
Plan identification number 501

EVENTIDE LUTHERAN HOME EMPLOYEE BENEFIT PLAN AND TRUST Benefits

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

401k Sponsoring company profile

EVENTIDE LUTHERAN HOME OF MOORHEAD has sponsored the creation of one or more 401k plans.

Company Name:EVENTIDE LUTHERAN HOME OF MOORHEAD
Employer identification number (EIN):411430427
NAIC Classification:623000
NAIC Description: Nursing and Residential Care Facilities

Form 5500 Filing Information

Submission information for form 5500 for 401k plan EVENTIDE LUTHERAN HOME EMPLOYEE BENEFIT PLAN AND TRUST

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5012021-10-01
5012020-10-01
5012019-10-01
5012018-10-01
5012017-10-01
5012016-10-01WADE STUBSON
5012015-10-01WADE STUBSON
5012014-10-01WADE STUBSON
5012013-10-01WADE STUBSON
5012012-10-01WADE STUBSON
5012011-10-01WADE STUBSON
5012010-10-01WADE STUBSON
5012009-10-01WADE STUBSON

Plan Statistics for EVENTIDE LUTHERAN HOME EMPLOYEE BENEFIT PLAN AND TRUST

401k plan membership statisitcs for EVENTIDE LUTHERAN HOME EMPLOYEE BENEFIT PLAN AND TRUST

Measure Date Value
2021: EVENTIDE LUTHERAN HOME EMPLOYEE BENEFIT PLAN AND TRUST 2021 401k membership
Total participants, beginning-of-year2021-10-01638
Total number of active participants reported on line 7a of the Form 55002021-10-01539
Total of all active and inactive participants2021-10-01539
2020: EVENTIDE LUTHERAN HOME EMPLOYEE BENEFIT PLAN AND TRUST 2020 401k membership
Total participants, beginning-of-year2020-10-01669
Total number of active participants reported on line 7a of the Form 55002020-10-01638
Total of all active and inactive participants2020-10-01638
2019: EVENTIDE LUTHERAN HOME EMPLOYEE BENEFIT PLAN AND TRUST 2019 401k membership
Total participants, beginning-of-year2019-10-01639
Total number of active participants reported on line 7a of the Form 55002019-10-01669
Total of all active and inactive participants2019-10-01669
2018: EVENTIDE LUTHERAN HOME EMPLOYEE BENEFIT PLAN AND TRUST 2018 401k membership
Total participants, beginning-of-year2018-10-01654
Total number of active participants reported on line 7a of the Form 55002018-10-01639
Total of all active and inactive participants2018-10-01639
2017: EVENTIDE LUTHERAN HOME EMPLOYEE BENEFIT PLAN AND TRUST 2017 401k membership
Total participants, beginning-of-year2017-10-01620
Total number of active participants reported on line 7a of the Form 55002017-10-01654
Total of all active and inactive participants2017-10-01654
2016: EVENTIDE LUTHERAN HOME EMPLOYEE BENEFIT PLAN AND TRUST 2016 401k membership
Total participants, beginning-of-year2016-10-01637
Total number of active participants reported on line 7a of the Form 55002016-10-01620
Total of all active and inactive participants2016-10-01620
2015: EVENTIDE LUTHERAN HOME EMPLOYEE BENEFIT PLAN AND TRUST 2015 401k membership
Total participants, beginning-of-year2015-10-01503
Total number of active participants reported on line 7a of the Form 55002015-10-01637
Total of all active and inactive participants2015-10-01637
2014: EVENTIDE LUTHERAN HOME EMPLOYEE BENEFIT PLAN AND TRUST 2014 401k membership
Total participants, beginning-of-year2014-10-01508
Total number of active participants reported on line 7a of the Form 55002014-10-01503
Total of all active and inactive participants2014-10-01503
2013: EVENTIDE LUTHERAN HOME EMPLOYEE BENEFIT PLAN AND TRUST 2013 401k membership
Total participants, beginning-of-year2013-10-01443
Total number of active participants reported on line 7a of the Form 55002013-10-01508
Total of all active and inactive participants2013-10-01508
2012: EVENTIDE LUTHERAN HOME EMPLOYEE BENEFIT PLAN AND TRUST 2012 401k membership
Total participants, beginning-of-year2012-10-01487
Total number of active participants reported on line 7a of the Form 55002012-10-01443
Total of all active and inactive participants2012-10-01443
2011: EVENTIDE LUTHERAN HOME EMPLOYEE BENEFIT PLAN AND TRUST 2011 401k membership
Total participants, beginning-of-year2011-10-01539
Total number of active participants reported on line 7a of the Form 55002011-10-01487
Total of all active and inactive participants2011-10-01487
2010: EVENTIDE LUTHERAN HOME EMPLOYEE BENEFIT PLAN AND TRUST 2010 401k membership
Total participants, beginning-of-year2010-10-01559
Total number of active participants reported on line 7a of the Form 55002010-10-01539
Total of all active and inactive participants2010-10-01539
2009: EVENTIDE LUTHERAN HOME EMPLOYEE BENEFIT PLAN AND TRUST 2009 401k membership
Total participants, beginning-of-year2009-10-01216
Total number of active participants reported on line 7a of the Form 55002009-10-01559
Total of all active and inactive participants2009-10-01559

Financial Data on EVENTIDE LUTHERAN HOME EMPLOYEE BENEFIT PLAN AND TRUST

Measure Date Value
2022 : EVENTIDE LUTHERAN HOME EMPLOYEE BENEFIT PLAN AND TRUST 2022 401k financial data
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year2022-09-30No
Was this plan covered by a fidelity bond2022-09-30No
If this is an individual account plan, was there a blackout period2022-09-30No
Were there any nonexempt tranactions with any party-in-interest2022-09-30No
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser2022-09-30No
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)2022-09-30No
Were any loans by the plan or fixed income obligations due to the plan in default2022-09-30No
Were any leases to which the plan was party in default or uncollectible2022-09-30No
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets2022-09-30No
Was there a failure to transmit to the plan any participant contributions2022-09-30No
Has the plan failed to provide any benefit when due under the plan2022-09-30No
Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-32022-09-30No
Did the plan have assets held for investment2022-09-30No
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser2022-09-30No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC2022-09-30No
2021 : EVENTIDE LUTHERAN HOME EMPLOYEE BENEFIT PLAN AND TRUST 2021 401k financial data
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year2021-09-30No
Was this plan covered by a fidelity bond2021-09-30No
If this is an individual account plan, was there a blackout period2021-09-30No
Were there any nonexempt tranactions with any party-in-interest2021-09-30No
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser2021-09-30No
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)2021-09-30No
Were any loans by the plan or fixed income obligations due to the plan in default2021-09-30No
Were any leases to which the plan was party in default or uncollectible2021-09-30No
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets2021-09-30No
Was there a failure to transmit to the plan any participant contributions2021-09-30No
Has the plan failed to provide any benefit when due under the plan2021-09-30No
Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-32021-09-30No
Did the plan have assets held for investment2021-09-30No
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser2021-09-30No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC2021-09-30No
2020 : EVENTIDE LUTHERAN HOME EMPLOYEE BENEFIT PLAN AND TRUST 2020 401k financial data
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year2020-09-30No
Was this plan covered by a fidelity bond2020-09-30No
If this is an individual account plan, was there a blackout period2020-09-30No
Were there any nonexempt tranactions with any party-in-interest2020-09-30No
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser2020-09-30No
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)2020-09-30No
Were any loans by the plan or fixed income obligations due to the plan in default2020-09-30No
Were any leases to which the plan was party in default or uncollectible2020-09-30No
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets2020-09-30No
Was there a failure to transmit to the plan any participant contributions2020-09-30No
Has the plan failed to provide any benefit when due under the plan2020-09-30No
Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-32020-09-30No
Did the plan have assets held for investment2020-09-30No
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser2020-09-30No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC2020-09-30No
2019 : EVENTIDE LUTHERAN HOME EMPLOYEE BENEFIT PLAN AND TRUST 2019 401k financial data
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year2019-09-30No
Was this plan covered by a fidelity bond2019-09-30No
If this is an individual account plan, was there a blackout period2019-09-30No
Were there any nonexempt tranactions with any party-in-interest2019-09-30No
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser2019-09-30No
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)2019-09-30No
Were any loans by the plan or fixed income obligations due to the plan in default2019-09-30No
Were any leases to which the plan was party in default or uncollectible2019-09-30No
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets2019-09-30No
Was there a failure to transmit to the plan any participant contributions2019-09-30No
Has the plan failed to provide any benefit when due under the plan2019-09-30No
Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-32019-09-30No
Did the plan have assets held for investment2019-09-30No
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser2019-09-30No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC2019-09-30No
2018 : EVENTIDE LUTHERAN HOME EMPLOYEE BENEFIT PLAN AND TRUST 2018 401k financial data
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year2018-09-30No
Was this plan covered by a fidelity bond2018-09-30No
If this is an individual account plan, was there a blackout period2018-09-30No
Were there any nonexempt tranactions with any party-in-interest2018-09-30No
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser2018-09-30No
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)2018-09-30No
Were any loans by the plan or fixed income obligations due to the plan in default2018-09-30No
Were any leases to which the plan was party in default or uncollectible2018-09-30No
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets2018-09-30No
Was there a failure to transmit to the plan any participant contributions2018-09-30No
Has the plan failed to provide any benefit when due under the plan2018-09-30No
Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-32018-09-30No
Did the plan have assets held for investment2018-09-30No
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser2018-09-30No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC2018-09-30No
2017 : EVENTIDE LUTHERAN HOME EMPLOYEE BENEFIT PLAN AND TRUST 2017 401k financial data
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year2017-09-30No
Was this plan covered by a fidelity bond2017-09-30No
If this is an individual account plan, was there a blackout period2017-09-30No
Were there any nonexempt tranactions with any party-in-interest2017-09-30No
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser2017-09-30No
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)2017-09-30No
Were any loans by the plan or fixed income obligations due to the plan in default2017-09-30No
Were any leases to which the plan was party in default or uncollectible2017-09-30No
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets2017-09-30No
Was there a failure to transmit to the plan any participant contributions2017-09-30No
Has the plan failed to provide any benefit when due under the plan2017-09-30No
Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-32017-09-30No
Did the plan have assets held for investment2017-09-30No
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser2017-09-30No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC2017-09-30No
2016 : EVENTIDE LUTHERAN HOME EMPLOYEE BENEFIT PLAN AND TRUST 2016 401k financial data
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year2016-09-30No
Was this plan covered by a fidelity bond2016-09-30No
If this is an individual account plan, was there a blackout period2016-09-30No
Were there any nonexempt tranactions with any party-in-interest2016-09-30No
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser2016-09-30No
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)2016-09-30No
Were any loans by the plan or fixed income obligations due to the plan in default2016-09-30No
Were any leases to which the plan was party in default or uncollectible2016-09-30No
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets2016-09-30No
Was there a failure to transmit to the plan any participant contributions2016-09-30No
Has the plan failed to provide any benefit when due under the plan2016-09-30No
Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-32016-09-30No
Did the plan have assets held for investment2016-09-30No
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser2016-09-30No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC2016-09-30No
2015 : EVENTIDE LUTHERAN HOME EMPLOYEE BENEFIT PLAN AND TRUST 2015 401k financial data
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year2015-09-30No
Was this plan covered by a fidelity bond2015-09-30No
If this is an individual account plan, was there a blackout period2015-09-30No
Were there any nonexempt tranactions with any party-in-interest2015-09-30No
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser2015-09-30No
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)2015-09-30No
Were any loans by the plan or fixed income obligations due to the plan in default2015-09-30No
Were any leases to which the plan was party in default or uncollectible2015-09-30No
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets2015-09-30No
Was there a failure to transmit to the plan any participant contributions2015-09-30No
Has the plan failed to provide any benefit when due under the plan2015-09-30No
Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-32015-09-30No
Did the plan have assets held for investment2015-09-30No
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser2015-09-30No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC2015-09-30No
2014 : EVENTIDE LUTHERAN HOME EMPLOYEE BENEFIT PLAN AND TRUST 2014 401k financial data
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year2014-09-30No
Was this plan covered by a fidelity bond2014-09-30No
If this is an individual account plan, was there a blackout period2014-09-30No
Were there any nonexempt tranactions with any party-in-interest2014-09-30No
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser2014-09-30No
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)2014-09-30No
Were any loans by the plan or fixed income obligations due to the plan in default2014-09-30No
Were any leases to which the plan was party in default or uncollectible2014-09-30No
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets2014-09-30No
Was there a failure to transmit to the plan any participant contributions2014-09-30No
Has the plan failed to provide any benefit when due under the plan2014-09-30No
Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-32014-09-30No
Did the plan have assets held for investment2014-09-30No
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser2014-09-30No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC2014-09-30No
2013 : EVENTIDE LUTHERAN HOME EMPLOYEE BENEFIT PLAN AND TRUST 2013 401k financial data
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year2013-09-30No
Was this plan covered by a fidelity bond2013-09-30No
If this is an individual account plan, was there a blackout period2013-09-30No
Were there any nonexempt tranactions with any party-in-interest2013-09-30No
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser2013-09-30No
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)2013-09-30No
Were any loans by the plan or fixed income obligations due to the plan in default2013-09-30No
Were any leases to which the plan was party in default or uncollectible2013-09-30No
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets2013-09-30No
Was there a failure to transmit to the plan any participant contributions2013-09-30No
Has the plan failed to provide any benefit when due under the plan2013-09-30No
Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-32013-09-30No
Did the plan have assets held for investment2013-09-30No
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser2013-09-30No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC2013-09-30No
2012 : EVENTIDE LUTHERAN HOME EMPLOYEE BENEFIT PLAN AND TRUST 2012 401k financial data
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year2012-09-30No
Was this plan covered by a fidelity bond2012-09-30No
If this is an individual account plan, was there a blackout period2012-09-30No
Were there any nonexempt tranactions with any party-in-interest2012-09-30No
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser2012-09-30No
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)2012-09-30No
Were any loans by the plan or fixed income obligations due to the plan in default2012-09-30No
Were any leases to which the plan was party in default or uncollectible2012-09-30No
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets2012-09-30No
Was there a failure to transmit to the plan any participant contributions2012-09-30No
Has the plan failed to provide any benefit when due under the plan2012-09-30No
Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-32012-09-30No
Did the plan have assets held for investment2012-09-30No
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser2012-09-30No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC2012-09-30No
2011 : EVENTIDE LUTHERAN HOME EMPLOYEE BENEFIT PLAN AND TRUST 2011 401k financial data
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year2011-09-30No
Was this plan covered by a fidelity bond2011-09-30No
If this is an individual account plan, was there a blackout period2011-09-30No
Were there any nonexempt tranactions with any party-in-interest2011-09-30No
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser2011-09-30No
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)2011-09-30No
Were any loans by the plan or fixed income obligations due to the plan in default2011-09-30No
Were any leases to which the plan was party in default or uncollectible2011-09-30No
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets2011-09-30No
Was there a failure to transmit to the plan any participant contributions2011-09-30No
Has the plan failed to provide any benefit when due under the plan2011-09-30No
Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-32011-09-30No
Did the plan have assets held for investment2011-09-30No
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser2011-09-30No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC2011-09-30No

Form 5500 Responses for EVENTIDE LUTHERAN HOME EMPLOYEE BENEFIT PLAN AND TRUST

2021: EVENTIDE LUTHERAN HOME EMPLOYEE BENEFIT PLAN AND TRUST 2021 form 5500 responses
2021-10-01Type of plan entitySingle employer plan
2021-10-01Plan funding arrangement – InsuranceYes
2021-10-01Plan funding arrangement – General assets of the sponsorYes
2021-10-01Plan benefit arrangement – InsuranceYes
2021-10-01Plan benefit arrangement – General assets of the sponsorYes
2020: EVENTIDE LUTHERAN HOME EMPLOYEE BENEFIT PLAN AND TRUST 2020 form 5500 responses
2020-10-01Type of plan entitySingle employer plan
2020-10-01Plan funding arrangement – InsuranceYes
2020-10-01Plan funding arrangement – General assets of the sponsorYes
2020-10-01Plan benefit arrangement – InsuranceYes
2020-10-01Plan benefit arrangement – General assets of the sponsorYes
2019: EVENTIDE LUTHERAN HOME EMPLOYEE BENEFIT PLAN AND TRUST 2019 form 5500 responses
2019-10-01Type of plan entitySingle employer plan
2019-10-01Plan funding arrangement – InsuranceYes
2019-10-01Plan funding arrangement – General assets of the sponsorYes
2019-10-01Plan benefit arrangement – InsuranceYes
2019-10-01Plan benefit arrangement – General assets of the sponsorYes
2018: EVENTIDE LUTHERAN HOME EMPLOYEE BENEFIT PLAN AND TRUST 2018 form 5500 responses
2018-10-01Type of plan entitySingle employer plan
2018-10-01Plan funding arrangement – InsuranceYes
2018-10-01Plan funding arrangement – General assets of the sponsorYes
2018-10-01Plan benefit arrangement – InsuranceYes
2018-10-01Plan benefit arrangement – General assets of the sponsorYes
2017: EVENTIDE LUTHERAN HOME EMPLOYEE BENEFIT PLAN AND TRUST 2017 form 5500 responses
2017-10-01Type of plan entitySingle employer plan
2017-10-01Plan funding arrangement – InsuranceYes
2017-10-01Plan funding arrangement – General assets of the sponsorYes
2017-10-01Plan benefit arrangement – InsuranceYes
2017-10-01Plan benefit arrangement – General assets of the sponsorYes
2016: EVENTIDE LUTHERAN HOME EMPLOYEE BENEFIT PLAN AND TRUST 2016 form 5500 responses
2016-10-01Type of plan entitySingle employer plan
2016-10-01Plan funding arrangement – InsuranceYes
2016-10-01Plan funding arrangement – General assets of the sponsorYes
2016-10-01Plan benefit arrangement – InsuranceYes
2016-10-01Plan benefit arrangement – General assets of the sponsorYes
2015: EVENTIDE LUTHERAN HOME EMPLOYEE BENEFIT PLAN AND TRUST 2015 form 5500 responses
2015-10-01Type of plan entitySingle employer plan
2015-10-01Plan funding arrangement – InsuranceYes
2015-10-01Plan funding arrangement – General assets of the sponsorYes
2015-10-01Plan benefit arrangement – InsuranceYes
2015-10-01Plan benefit arrangement – General assets of the sponsorYes
2014: EVENTIDE LUTHERAN HOME EMPLOYEE BENEFIT PLAN AND TRUST 2014 form 5500 responses
2014-10-01Type of plan entitySingle employer plan
2014-10-01Plan funding arrangement – InsuranceYes
2014-10-01Plan funding arrangement – General assets of the sponsorYes
2014-10-01Plan benefit arrangement – InsuranceYes
2014-10-01Plan benefit arrangement – General assets of the sponsorYes
2013: EVENTIDE LUTHERAN HOME EMPLOYEE BENEFIT PLAN AND TRUST 2013 form 5500 responses
2013-10-01Type of plan entitySingle employer plan
2013-10-01Plan funding arrangement – InsuranceYes
2013-10-01Plan funding arrangement – General assets of the sponsorYes
2013-10-01Plan benefit arrangement – InsuranceYes
2013-10-01Plan benefit arrangement – General assets of the sponsorYes
2012: EVENTIDE LUTHERAN HOME EMPLOYEE BENEFIT PLAN AND TRUST 2012 form 5500 responses
2012-10-01Type of plan entitySingle employer plan
2012-10-01Plan funding arrangement – InsuranceYes
2012-10-01Plan funding arrangement – General assets of the sponsorYes
2012-10-01Plan benefit arrangement – InsuranceYes
2012-10-01Plan benefit arrangement – General assets of the sponsorYes
2011: EVENTIDE LUTHERAN HOME EMPLOYEE BENEFIT PLAN AND TRUST 2011 form 5500 responses
2011-10-01Type of plan entitySingle employer plan
2011-10-01Plan funding arrangement – InsuranceYes
2011-10-01Plan funding arrangement – General assets of the sponsorYes
2011-10-01Plan benefit arrangement – InsuranceYes
2011-10-01Plan benefit arrangement – General assets of the sponsorYes
2010: EVENTIDE LUTHERAN HOME EMPLOYEE BENEFIT PLAN AND TRUST 2010 form 5500 responses
2010-10-01Type of plan entitySingle employer plan
2010-10-01Plan funding arrangement – InsuranceYes
2010-10-01Plan funding arrangement – General assets of the sponsorYes
2010-10-01Plan benefit arrangement – InsuranceYes
2010-10-01Plan benefit arrangement – General assets of the sponsorYes
2009: EVENTIDE LUTHERAN HOME EMPLOYEE BENEFIT PLAN AND TRUST 2009 form 5500 responses
2009-10-01Type of plan entitySingle employer plan
2009-10-01This submission is the final filingNo
2009-10-01Plan funding arrangement – InsuranceYes
2009-10-01Plan funding arrangement – General assets of the sponsorYes
2009-10-01Plan benefit arrangement – InsuranceYes
2009-10-01Plan benefit arrangement – General assets of the sponsorYes

Insurance Providers Used on plan

AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 )
Policy contract number62444
Policy instance 3
Insurance contract or identification number62444
Number of Individuals Covered97
Insurance policy start date2021-10-01
Insurance policy end date2022-09-30
Total amount of commissions paid to insurance brokerUSD $6,652
Total amount of fees paid to insurance companyUSD $0
Temporary Disability Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENT
Welfare Benefit Premiums Paid to CarrierUSD $34,900
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6,640
Insurance broker organization code?3
HEALTHPARTNERS INSURANCE CO (National Association of Insurance Commissioners NAIC id number: 44547 )
Policy contract number36557
Policy instance 8
Insurance contract or identification number36557
Number of Individuals Covered702
Insurance policy start date2022-01-01
Insurance policy end date2022-09-30
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $45,825
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $4,895,959
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Amount paid for insurance broker fees26924
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA (National Association of Insurance Commissioners NAIC id number: 55891 )
Policy contract number250804
Policy instance 1
Insurance contract or identification number250804
Insurance policy start date2021-10-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,737,558
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 )
Policy contract number36776
Policy instance 2
Insurance contract or identification number36776
Number of Individuals Covered292
Insurance policy start date2021-10-01
Insurance policy end date2022-09-30
Total amount of commissions paid to insurance brokerUSD $4,350
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $64,011
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,350
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLUG0ASQX
Policy instance 4
Insurance contract or identification numberGLUG0ASQX
Number of Individuals Covered525
Insurance policy start date2021-10-01
Insurance policy end date2022-09-30
Total amount of commissions paid to insurance brokerUSD $2,424
Total amount of fees paid to insurance companyUSD $1,006
Life Insurance Welfare BenefitYes
Other welfare benefits providedLIFE & AD&D
Welfare Benefit Premiums Paid to CarrierUSD $24,243
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,408
Amount paid for insurance broker fees1006
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLTD0ASQX
Policy instance 5
Insurance contract or identification numberGLTD0ASQX
Number of Individuals Covered525
Insurance policy start date2021-10-01
Insurance policy end date2022-09-30
Total amount of commissions paid to insurance brokerUSD $12,562
Total amount of fees paid to insurance companyUSD $6,806
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $167,495
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $7,289
Amount paid for insurance broker fees6806
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGVTL0ASQX
Policy instance 6
Insurance contract or identification numberGVTL0ASQX
Number of Individuals Covered163
Insurance policy start date2021-10-01
Insurance policy end date2022-09-30
Total amount of commissions paid to insurance brokerUSD $9,431
Total amount of fees paid to insurance companyUSD $2,790
Life Insurance Welfare BenefitYes
Other welfare benefits providedVOLUNTARY LIFE
Welfare Benefit Premiums Paid to CarrierUSD $62,870
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,477
Amount paid for insurance broker fees2790
Insurance broker organization code?3
AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 )
Policy contract number62444
Policy instance 7
Insurance contract or identification number62444
Number of Individuals Covered92
Insurance policy start date2021-10-01
Insurance policy end date2022-09-30
Total amount of commissions paid to insurance brokerUSD $2,598
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedCANCER
Welfare Benefit Premiums Paid to CarrierUSD $21,437
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,598
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA (National Association of Insurance Commissioners NAIC id number: 55891 )
Policy contract number250804
Policy instance 1
Insurance contract or identification number250804
Insurance policy start date2020-10-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,839,026
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 )
Policy contract number36776
Policy instance 2
Insurance contract or identification number36776
Number of Individuals Covered318
Insurance policy start date2020-10-01
Insurance policy end date2021-09-30
Total amount of commissions paid to insurance brokerUSD $9,697
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $64,644
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $9,697
Insurance broker organization code?3
AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 )
Policy contract number62444
Policy instance 3
Insurance contract or identification number62444
Number of Individuals Covered119
Insurance policy start date2020-10-01
Insurance policy end date2021-09-30
Total amount of commissions paid to insurance brokerUSD $5,621
Total amount of fees paid to insurance companyUSD $0
Temporary Disability Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENT
Welfare Benefit Premiums Paid to CarrierUSD $33,730
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,585
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLUG0ASQX
Policy instance 4
Insurance contract or identification numberGLUG0ASQX
Number of Individuals Covered600
Insurance policy start date2020-10-01
Insurance policy end date2021-09-30
Total amount of commissions paid to insurance brokerUSD $2,564
Total amount of fees paid to insurance companyUSD $2,419
Life Insurance Welfare BenefitYes
Other welfare benefits providedLIFE & AD&D
Welfare Benefit Premiums Paid to CarrierUSD $25,630
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $663
Amount paid for insurance broker fees1613
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLTD0ASQX
Policy instance 5
Insurance contract or identification numberGLTD0ASQX
Number of Individuals Covered600
Insurance policy start date2020-10-01
Insurance policy end date2021-09-30
Total amount of commissions paid to insurance brokerUSD $12,962
Total amount of fees paid to insurance companyUSD $16,157
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $172,827
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,318
Amount paid for insurance broker fees10771
Insurance broker organization code?3
AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 )
Policy contract number62444
Policy instance 7
Insurance contract or identification number62444
Number of Individuals Covered94
Insurance policy start date2020-10-01
Insurance policy end date2021-09-30
Total amount of commissions paid to insurance brokerUSD $2,275
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedCANCER
Welfare Benefit Premiums Paid to CarrierUSD $19,815
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,275
HEALTHPARTNERS INSURANCE CO (National Association of Insurance Commissioners NAIC id number: 44547 )
Policy contract number36557
Policy instance 8
Insurance contract or identification number36557
Number of Individuals Covered783
Insurance policy start date2021-01-01
Insurance policy end date2021-09-30
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $47,051
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $5,439,059
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Amount paid for insurance broker fees42761
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGVTL0ASQX
Policy instance 6
Insurance contract or identification numberGVTL0ASQX
Number of Individuals Covered194
Insurance policy start date2020-10-01
Insurance policy end date2021-09-30
Total amount of commissions paid to insurance brokerUSD $10,690
Total amount of fees paid to insurance companyUSD $6,437
Life Insurance Welfare BenefitYes
Other welfare benefits providedVOLUNTARY LIFE
Welfare Benefit Premiums Paid to CarrierUSD $71,269
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $8,013
Amount paid for insurance broker fees4291
Insurance broker organization code?3
AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 )
Policy contract number62444
Policy instance 3
Insurance contract or identification number62444
Number of Individuals Covered120
Insurance policy start date2019-10-01
Insurance policy end date2020-09-30
Total amount of commissions paid to insurance brokerUSD $6,527
Total amount of fees paid to insurance companyUSD $0
Temporary Disability Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENT
Welfare Benefit Premiums Paid to CarrierUSD $79,671
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6,479
NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 )
Policy contract number36776
Policy instance 2
Insurance contract or identification number36776
Number of Individuals Covered741
Insurance policy start date2019-10-01
Insurance policy end date2020-09-30
Total amount of commissions paid to insurance brokerUSD $10,609
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $70,724
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $10,609
Insurance broker organization code?3
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA (National Association of Insurance Commissioners NAIC id number: 55891 )
Policy contract number250804
Policy instance 1
Insurance contract or identification number250804
Number of Individuals Covered0
Insurance policy start date2019-10-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $22,067
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,812,751
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $22,067
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLUG0ASQX
Policy instance 4
Insurance contract or identification numberGLUG0ASQX
Number of Individuals Covered1338
Insurance policy start date2019-10-01
Insurance policy end date2020-09-30
Total amount of commissions paid to insurance brokerUSD $2,684
Total amount of fees paid to insurance companyUSD $2,334
Life Insurance Welfare BenefitYes
Other welfare benefits providedLIFE & AD&D
Welfare Benefit Premiums Paid to CarrierUSD $26,837
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,684
Amount paid for insurance broker fees1556
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLTD0ASQX
Policy instance 5
Insurance contract or identification numberGLTD0ASQX
Number of Individuals Covered1338
Insurance policy start date2019-10-01
Insurance policy end date2020-09-30
Total amount of commissions paid to insurance brokerUSD $13,419
Total amount of fees paid to insurance companyUSD $15,498
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $178,919
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $13,419
Amount paid for insurance broker fees10332
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGVTL0ASQX
Policy instance 6
Insurance contract or identification numberGVTL0ASQX
Number of Individuals Covered448
Insurance policy start date2019-10-01
Insurance policy end date2020-09-30
Total amount of commissions paid to insurance brokerUSD $10,678
Total amount of fees paid to insurance companyUSD $6,329
Life Insurance Welfare BenefitYes
Other welfare benefits providedVOLUNTARY LIFE
Welfare Benefit Premiums Paid to CarrierUSD $71,184
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $10,678
Amount paid for insurance broker fees4219
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 )
Policy contract number62444
Policy instance 8
Insurance contract or identification number62444
Number of Individuals Covered101
Insurance policy start date2019-10-01
Insurance policy end date2020-09-30
Total amount of commissions paid to insurance brokerUSD $3,037
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedCANCER
Welfare Benefit Premiums Paid to CarrierUSD $25,281
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,037
HEALTHPARTNERS INSURANCE CO (National Association of Insurance Commissioners NAIC id number: 44547 )
Policy contract number36557
Policy instance 9
Insurance contract or identification number36557
Number of Individuals Covered991
Insurance policy start date2020-01-01
Insurance policy end date2020-09-30
Total amount of commissions paid to insurance brokerUSD $84,202
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $4,522,581
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $84,202
Insurance broker organization code?3
121 BENEFITS (National Association of Insurance Commissioners NAIC id number: 52429 )
Policy contract number90165
Policy instance 7
Insurance contract or identification number90165
Number of Individuals Covered68
Insurance policy start date2020-10-01
Insurance policy end date2021-09-30
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 )
Policy contract number36776
Policy instance 2
Insurance contract or identification number36776
Number of Individuals Covered349
Insurance policy start date2018-10-01
Insurance policy end date2019-09-30
Total amount of commissions paid to insurance brokerUSD $10,187
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $67,916
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $10,187
Insurance broker organization code?3
AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 )
Policy contract number62444
Policy instance 3
Insurance contract or identification number62444
Number of Individuals Covered134
Insurance policy start date2018-10-01
Insurance policy end date2019-09-30
Total amount of commissions paid to insurance brokerUSD $7,875
Total amount of fees paid to insurance companyUSD $0
Temporary Disability Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENT
Welfare Benefit Premiums Paid to CarrierUSD $46,897
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $7,819
AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 )
Policy contract number62444
Policy instance 8
Insurance contract or identification number62444
Number of Individuals Covered120
Insurance policy start date2018-10-01
Insurance policy end date2019-09-30
Total amount of commissions paid to insurance brokerUSD $4,026
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedCANCER
Welfare Benefit Premiums Paid to CarrierUSD $30,589
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,026
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGVTL0ASQX
Policy instance 6
Insurance contract or identification numberGVTL0ASQX
Number of Individuals Covered229
Insurance policy start date2018-10-01
Insurance policy end date2019-09-30
Total amount of commissions paid to insurance brokerUSD $10,636
Total amount of fees paid to insurance companyUSD $6,621
Life Insurance Welfare BenefitYes
Other welfare benefits providedVOLUNTARY LIFE
Welfare Benefit Premiums Paid to CarrierUSD $71,089
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $10,636
Amount paid for insurance broker fees4414
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLUG0ASQX
Policy instance 4
Insurance contract or identification numberGLUG0ASQX
Number of Individuals Covered639
Insurance policy start date2018-10-01
Insurance policy end date2019-09-30
Total amount of commissions paid to insurance brokerUSD $2,543
Total amount of fees paid to insurance companyUSD $2,304
Life Insurance Welfare BenefitYes
Other welfare benefits providedLIFE & AD&D
Welfare Benefit Premiums Paid to CarrierUSD $25,496
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,543
Amount paid for insurance broker fees1536
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLTD0ASQX
Policy instance 5
Insurance contract or identification numberGLTD0ASQX
Number of Individuals Covered639
Insurance policy start date2018-10-01
Insurance policy end date2019-09-30
Total amount of commissions paid to insurance brokerUSD $12,595
Total amount of fees paid to insurance companyUSD $15,165
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $168,376
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $12,595
Amount paid for insurance broker fees10110
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
121 BENEFITS (National Association of Insurance Commissioners NAIC id number: 52429 )
Policy contract number90165
Policy instance 7
Insurance contract or identification number90165
Number of Individuals Covered68
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $7,832
Total amount of fees paid to insurance companyUSD $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $7,832
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA (National Association of Insurance Commissioners NAIC id number: 55891 )
Policy contract number10258
Policy instance 1
Insurance contract or identification number10258
Number of Individuals Covered919
Insurance policy start date2018-10-01
Insurance policy end date2019-09-30
Total amount of commissions paid to insurance brokerUSD $11,596
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,620,299
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,798
NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 )
Policy contract number36776
Policy instance 2
Insurance contract or identification number36776
Number of Individuals Covered667
Insurance policy start date2017-10-01
Insurance policy end date2018-09-30
Total amount of commissions paid to insurance brokerUSD $6,695
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $44,631
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number50790-1611
Policy instance 3
Insurance contract or identification number50790-1611
Number of Individuals Covered438
Insurance policy start date2017-10-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $1,448
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $9,580
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 )
Policy contract number62444
Policy instance 4
Insurance contract or identification number62444
Number of Individuals Covered149
Insurance policy start date2017-10-01
Insurance policy end date2018-09-30
Total amount of commissions paid to insurance brokerUSD $13,561
Total amount of fees paid to insurance companyUSD $0
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $48,358
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLTD0ASQX
Policy instance 6
Insurance contract or identification numberGLTD0ASQX
Number of Individuals Covered654
Insurance policy start date2017-10-01
Insurance policy end date2018-09-30
Total amount of commissions paid to insurance brokerUSD $12,673
Total amount of fees paid to insurance companyUSD $14,248
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $168,969
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
121 BENEFITS (National Association of Insurance Commissioners NAIC id number: 52429 )
Policy contract number90165
Policy instance 8
Insurance contract or identification number90165
Number of Individuals Covered85
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $8,444
Total amount of fees paid to insurance companyUSD $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 )
Policy contract number36776
Policy instance 9
Insurance contract or identification number36776
Number of Individuals Covered667
Insurance policy start date2017-10-01
Insurance policy end date2018-09-30
Total amount of commissions paid to insurance brokerUSD $6,695
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $44,631
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 )
Policy contract number62444
Policy instance 10
Insurance contract or identification number62444
Number of Individuals Covered107
Insurance policy start date2017-10-01
Insurance policy end date2018-09-30
Total amount of commissions paid to insurance brokerUSD $6,381
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedCANCER
Welfare Benefit Premiums Paid to CarrierUSD $3,757
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLUG0ASQX
Policy instance 5
Insurance contract or identification numberGLUG0ASQX
Number of Individuals Covered654
Insurance policy start date2017-10-01
Insurance policy end date2018-09-30
Total amount of commissions paid to insurance brokerUSD $2,571
Total amount of fees paid to insurance companyUSD $2,182
Life Insurance Welfare BenefitYes
Other welfare benefits providedLIFE & AD&D
Welfare Benefit Premiums Paid to CarrierUSD $25,172
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA (National Association of Insurance Commissioners NAIC id number: 55891 )
Policy contract number10258
Policy instance 1
Insurance contract or identification number10258
Number of Individuals Covered812
Insurance policy start date2017-10-01
Insurance policy end date2018-09-30
Total amount of commissions paid to insurance brokerUSD $27,251
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,575,303
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGVTL0ASQX
Policy instance 7
Insurance contract or identification numberGVTL0ASQX
Number of Individuals Covered256
Insurance policy start date2017-10-01
Insurance policy end date2018-10-01
Total amount of commissions paid to insurance brokerUSD $10,839
Total amount of fees paid to insurance companyUSD $5,634
Life Insurance Welfare BenefitYes
Other welfare benefits providedVOLUNTARY LIFE
Welfare Benefit Premiums Paid to CarrierUSD $72,261
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )
Policy contract number753731
Policy instance 2
Insurance contract or identification number753731
Number of Individuals Covered54
Insurance policy start date2016-01-01
Insurance policy end date2016-12-31
Total amount of commissions paid to insurance brokerUSD $858
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $9,365
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $858
Insurance broker organization code?3
Insurance broker namePREMIER BENEFITS GROUP, INC
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA (National Association of Insurance Commissioners NAIC id number: 55891 )
Policy contract number10258
Policy instance 1
Insurance contract or identification number10258
Number of Individuals Covered752
Insurance policy start date2015-10-01
Insurance policy end date2016-09-30
Total amount of commissions paid to insurance brokerUSD $7,192
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,252,148
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $7,192
Insurance broker nameWARNER & COMPANY
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number50790-1611
Policy instance 3
Insurance contract or identification number50790-1611
Number of Individuals Covered395
Insurance policy start date2015-10-01
Insurance policy end date2016-09-30
Total amount of commissions paid to insurance brokerUSD $4,772
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $41,000
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,181
Insurance broker nameEE DORSETT & ASSOCIATES
AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 )
Policy contract number62444
Policy instance 4
Insurance contract or identification number62444
Number of Individuals Covered175
Insurance policy start date2015-10-01
Insurance policy end date2016-09-30
Total amount of commissions paid to insurance brokerUSD $14,668
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $81,120
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $14,574
Insurance broker nameWILLIAM FLICKINGER
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLUG0ASQX
Policy instance 5
Insurance contract or identification numberGLUG0ASQX
Number of Individuals Covered540
Insurance policy start date2015-06-01
Insurance policy end date2016-06-01
Total amount of commissions paid to insurance brokerUSD $1,884
Total amount of fees paid to insurance companyUSD $904
Life Insurance Welfare BenefitYes
Other welfare benefits providedLIFE & AD&D
Welfare Benefit Premiums Paid to CarrierUSD $18,843
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,884
Amount paid for insurance broker fees904
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
Insurance broker namePREMIER BENEFITS GROUP INC.
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLTD0ASQX
Policy instance 6
Insurance contract or identification numberGLTD0ASQX
Number of Individuals Covered541
Insurance policy start date2015-06-01
Insurance policy end date2016-06-01
Total amount of commissions paid to insurance brokerUSD $8,655
Total amount of fees paid to insurance companyUSD $5,486
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $115,398
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $8,655
Amount paid for insurance broker fees5486
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
Insurance broker namePREMIER BENEFITS GROUP INC.
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGVTL0ASQX
Policy instance 7
Insurance contract or identification numberGVTL0ASQX
Number of Individuals Covered210
Insurance policy start date2015-06-01
Insurance policy end date2016-06-01
Total amount of commissions paid to insurance brokerUSD $8,180
Total amount of fees paid to insurance companyUSD $2,765
Life Insurance Welfare BenefitYes
Other welfare benefits providedVOLUNTARY LIFE
Welfare Benefit Premiums Paid to CarrierUSD $54,534
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $8,180
Amount paid for insurance broker fees2765
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
Insurance broker namePREMIER BENEFITS GROUP INC.
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberG00ASQX
Policy instance 7
Insurance contract or identification numberG00ASQX
Number of Individuals Covered214
Insurance policy start date2014-06-01
Insurance policy end date2015-06-01
Total amount of commissions paid to insurance brokerUSD $8,202
Total amount of fees paid to insurance companyUSD $805
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Life Insurance Welfare BenefitYes
Other welfare benefits providedVOLUNTARY LIFE
Welfare Benefit Premiums Paid to CarrierUSD $54,680
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $8,202
Amount paid for insurance broker fees805
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
Insurance broker namePRAIRIE BENEFITS INC.
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA (National Association of Insurance Commissioners NAIC id number: 55891 )
Policy contract number10258
Policy instance 1
Insurance contract or identification number10258
Number of Individuals Covered309
Insurance policy start date2014-10-01
Insurance policy end date2015-09-30
Total amount of commissions paid to insurance brokerUSD $6,020
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Health Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,220,375
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6,020
Insurance broker nameWARNER & COMPANY
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number12273022
Policy instance 2
Insurance contract or identification number12273022
Number of Individuals Covered41
Insurance policy start date2014-10-01
Insurance policy end date2015-09-30
Total amount of commissions paid to insurance brokerUSD $696
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $41,195
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $696
Insurance broker namePRAIRIE BENEFITS INC.
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number50790-1611
Policy instance 3
Insurance contract or identification number50790-1611
Number of Individuals Covered375
Insurance policy start date2014-10-10
Insurance policy end date2015-09-30
Total amount of commissions paid to insurance brokerUSD $4,451
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $32,318
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,967
Insurance broker nameEE DORSETT & ASSOCIATES
AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 )
Policy contract number62444
Policy instance 4
Insurance contract or identification number62444
Number of Individuals Covered175
Insurance policy start date2014-10-01
Insurance policy end date2015-09-30
Total amount of commissions paid to insurance brokerUSD $27,716
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $81,779
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $27,577
Additional information about fees paid to insurance brokerN
Insurance broker nameKEELER & ASSOCIATES
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberG00ASQX
Policy instance 5
Insurance contract or identification numberG00ASQX
Number of Individuals Covered511
Insurance policy start date2014-06-01
Insurance policy end date2015-06-01
Total amount of commissions paid to insurance brokerUSD $1,757
Total amount of fees paid to insurance companyUSD $248
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Life Insurance Welfare BenefitYes
Other welfare benefits providedLIFE & AD&D
Welfare Benefit Premiums Paid to CarrierUSD $17,547
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,757
Amount paid for insurance broker fees248
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
Insurance broker namePRAIRIE BENEFITS INC.
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberG00ASQX
Policy instance 6
Insurance contract or identification numberG00ASQX
Number of Individuals Covered514
Insurance policy start date2014-06-01
Insurance policy end date2015-06-01
Total amount of commissions paid to insurance brokerUSD $7,972
Total amount of fees paid to insurance companyUSD $1,515
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $106,288
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $7,972
Amount paid for insurance broker fees1515
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
Insurance broker namePRAIRIE BENEFITS INC.
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number50790-1611
Policy instance 5
Insurance contract or identification number50790-1611
Number of Individuals Covered325
Insurance policy start date2013-10-10
Insurance policy end date2014-09-30
Total amount of commissions paid to insurance brokerUSD $4,146
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $27,638
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,764
Insurance broker nameEE DORSETT & ASSOCIATES
MADISON NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65781 )
Policy contract number1184
Policy instance 1
Insurance contract or identification number1184
Number of Individuals Covered412
Insurance policy start date2013-10-01
Insurance policy end date2014-09-30
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $6,039
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $86,062
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Amount paid for insurance broker fees6039
Additional information about fees paid to insurance brokerBROKER FEES
Insurance broker organization code?3
Insurance broker namePRAIRIE BENEFITS GROUP INC.
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract numberGL146762
Policy instance 2
Insurance contract or identification numberGL146762
Number of Individuals Covered439
Insurance policy start date2014-01-01
Insurance policy end date2014-12-31
Total amount of commissions paid to insurance brokerUSD $1,914
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $105,737
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,914
Insurance broker namePREMIER BENEFITS GROUP, INC.
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA (National Association of Insurance Commissioners NAIC id number: 55891 )
Policy contract number10258
Policy instance 3
Insurance contract or identification number10258
Number of Individuals Covered692
Insurance policy start date2013-10-01
Insurance policy end date2014-09-30
Total amount of commissions paid to insurance brokerUSD $19,130
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Health Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $945,566
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $19,130
Insurance broker nameWARNER & COMPANY
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number12273022
Policy instance 4
Insurance contract or identification number12273022
Number of Individuals Covered42
Insurance policy start date2014-01-01
Insurance policy end date2014-12-31
Total amount of commissions paid to insurance brokerUSD $816
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $11,841
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $816
Insurance broker namePRAIRIE BENEFITS INC.
HCC LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 92711 )
Policy contract numberHCL13816
Policy instance 1
Insurance contract or identification numberHCL13816
Insurance policy start date2012-10-01
Insurance policy end date2013-09-30
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Health Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract numberGL146762
Policy instance 3
Insurance contract or identification numberGL146762
Number of Individuals Covered439
Insurance policy start date2013-02-01
Insurance policy end date2014-01-31
Total amount of commissions paid to insurance brokerUSD $3,168
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $61,750
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,168
Insurance broker name
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA (National Association of Insurance Commissioners NAIC id number: 55891 )
Policy contract number10258
Policy instance 4
Insurance contract or identification number10258
Number of Individuals Covered646
Insurance policy start date2012-10-01
Insurance policy end date2013-09-30
Total amount of commissions paid to insurance brokerUSD $18,613
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Health Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $747,194
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $18,613
Insurance broker nameWARNER & COMPANY
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number12273022
Policy instance 5
Insurance contract or identification number12273022
Number of Individuals Covered62
Insurance policy start date2013-01-01
Insurance policy end date2013-12-31
Total amount of commissions paid to insurance brokerUSD $934
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $15,159
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $934
Insurance broker namePRAIRIE BENEFITS INC.
MADISON NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65781 )
Policy contract number1184
Policy instance 2
Insurance contract or identification number1184
Number of Individuals Covered421
Insurance policy start date2012-10-01
Insurance policy end date2013-09-30
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $8,688
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $86,876
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Amount paid for insurance broker fees8688
Additional information about fees paid to insurance brokerBROKER FEES
Insurance broker organization code?3
Insurance broker namePRAIRIE BENEFITS GROUP INC.
MADISON NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65781 )
Policy contract number1184
Policy instance 2
Insurance contract or identification number1184
Number of Individuals Covered433
Insurance policy start date2011-10-01
Insurance policy end date2012-09-30
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $8,241
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $82,407
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
HCC LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 92711 )
Policy contract numberHCL13816
Policy instance 1
Insurance contract or identification numberHCL13816
Number of Individuals Covered205
Insurance policy start date2011-10-01
Insurance policy end date2012-09-30
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $25,644
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract numberGL146762
Policy instance 3
Insurance contract or identification numberGL146762
Number of Individuals Covered410
Insurance policy start date2012-02-01
Insurance policy end date2013-01-31
Total amount of commissions paid to insurance brokerUSD $3,395
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $57,390
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number12273022
Policy instance 5
Insurance contract or identification number12273022
Number of Individuals Covered63
Insurance policy start date2012-01-01
Insurance policy end date2012-12-31
Total amount of commissions paid to insurance brokerUSD $996
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $16,917
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA (National Association of Insurance Commissioners NAIC id number: 55891 )
Policy contract number10258
Policy instance 4
Insurance contract or identification number10258
Number of Individuals Covered431
Insurance policy start date2012-01-01
Insurance policy end date2012-12-31
Total amount of commissions paid to insurance brokerUSD $16,952
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Health Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $587,590
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
HCC LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 92711 )
Policy contract numberHCL13816
Policy instance 1
Insurance contract or identification numberHCL13816
Number of Individuals Covered205
Insurance policy start date2010-10-01
Insurance policy end date2011-09-30
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $128,860
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract numberGL146762
Policy instance 3
Insurance contract or identification numberGL146762
Number of Individuals Covered292
Insurance policy start date2011-02-01
Insurance policy end date2012-01-31
Total amount of commissions paid to insurance brokerUSD $1,919
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $23,382
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
BLUE CROSS BLUE SHIELD OF NORTH DAKOTA (National Association of Insurance Commissioners NAIC id number: 55891 )
Policy contract number10258
Policy instance 4
Insurance contract or identification number10258
Number of Individuals Covered358
Insurance policy start date2011-01-01
Insurance policy end date2011-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Health Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $491,769
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
MADISON NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65781 )
Policy contract number1184
Policy instance 2
Insurance contract or identification number1184
Number of Individuals Covered417
Insurance policy start date2010-10-01
Insurance policy end date2011-09-30
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $7,636
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $76,356
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No

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