401k Plan data: GRAND RIVER MEDICAL GROUP, P.C. WELFARE BENEFITS PLAN plan

GRAND RIVER MEDICAL GROUP, P.C. WELFARE BENEFITS PLAN 401k Plan overview

Plan Name	GRAND RIVER MEDICAL GROUP, P.C. WELFARE BENEFITS PLAN
Plan identification number	508

GRAND RIVER MEDICAL GROUP, P.C. WELFARE BENEFITS PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Life insurance Dental Vision Long-term disability cover Death benefits (include travel accident but not life insurance) Other welfare benefit cover

401k Sponsoring company profile

DUBUQUE INTERNAL MEDICINE PC DBA GRAND RIVER MEDICAL GROUP has sponsored the creation of one or more 401k plans.

Company Name: DUBUQUE INTERNAL MEDICINE PC DBA GRAND RIVER MEDICAL GROUP

Employer identification number (EIN): 420848123

NAIC Classification: 621111
NAIC Description: Offices of Physicians (except Mental Health Specialists)

Form 5500 Filing Information

Submission information for form 5500 for 401k plan GRAND RIVER MEDICAL GROUP, P.C. WELFARE BENEFITS PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
508 2022-01-01 RONALD IVERSON 2023-07-19
508 2021-01-01 RONALD IVERSON 2022-02-25
508 2020-01-01 RONALD IVERSON 2021-07-12
508 2019-01-01 RONALD IVERSON 2020-07-06
508 2018-04-01

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Date Sponsor Signed
508	2022-01-01	RONALD IVERSON	2023-07-19
508	2021-01-01	RONALD IVERSON	2022-02-25
508	2020-01-01	RONALD IVERSON	2021-07-12
508	2019-01-01	RONALD IVERSON		2020-07-06
508	2018-04-01

Plan Statistics for GRAND RIVER MEDICAL GROUP, P.C. WELFARE BENEFITS PLAN

401k plan membership statisitcs for GRAND RIVER MEDICAL GROUP, P.C. WELFARE BENEFITS PLAN

Measure Date Value
2022: GRAND RIVER MEDICAL GROUP, P.C. WELFARE BENEFITS PLAN 2022 401k membership
Total participants, beginning-of-year 2022-01-01 314
Total number of active participants reported on line 7a of the Form 5500 2022-01-01 319
Number of retired or separated participants receiving benefits 2022-01-01 3
Total of all active and inactive participants 2022-01-01 322
2021: GRAND RIVER MEDICAL GROUP, P.C. WELFARE BENEFITS PLAN 2021 401k membership
Total participants, beginning-of-year 2021-01-01 303
Total number of active participants reported on line 7a of the Form 5500 2021-01-01 308
Number of retired or separated participants receiving benefits 2021-01-01 2
Total of all active and inactive participants 2021-01-01 310
2020: GRAND RIVER MEDICAL GROUP, P.C. WELFARE BENEFITS PLAN 2020 401k membership
Total participants, beginning-of-year 2020-01-01 285
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 296
Number of retired or separated participants receiving benefits 2020-01-01 2
Total of all active and inactive participants 2020-01-01 298
2019: GRAND RIVER MEDICAL GROUP, P.C. WELFARE BENEFITS PLAN 2019 401k membership
Total participants, beginning-of-year 2019-01-01 297
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 282
Number of retired or separated participants receiving benefits 2019-01-01 6
Total of all active and inactive participants 2019-01-01 288
2018: GRAND RIVER MEDICAL GROUP, P.C. WELFARE BENEFITS PLAN 2018 401k membership
Total participants, beginning-of-year 2018-04-01 289
Total number of active participants reported on line 7a of the Form 5500 2018-04-01 297
Number of retired or separated participants receiving benefits 2018-04-01 4
Total of all active and inactive participants 2018-04-01 301

Measure	Date	Value
2022: GRAND RIVER MEDICAL GROUP, P.C. WELFARE BENEFITS PLAN 2022 401k membership
Total participants, beginning-of-year	2022-01-01	314
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	319
Number of retired or separated participants receiving benefits	2022-01-01	3
Total of all active and inactive participants	2022-01-01	322
2021: GRAND RIVER MEDICAL GROUP, P.C. WELFARE BENEFITS PLAN 2021 401k membership
Total participants, beginning-of-year	2021-01-01	303
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	308
Number of retired or separated participants receiving benefits	2021-01-01	2
Total of all active and inactive participants	2021-01-01	310
2020: GRAND RIVER MEDICAL GROUP, P.C. WELFARE BENEFITS PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	285
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	296
Number of retired or separated participants receiving benefits	2020-01-01	2
Total of all active and inactive participants	2020-01-01	298
2019: GRAND RIVER MEDICAL GROUP, P.C. WELFARE BENEFITS PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	297
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	282
Number of retired or separated participants receiving benefits	2019-01-01	6
Total of all active and inactive participants	2019-01-01	288
2018: GRAND RIVER MEDICAL GROUP, P.C. WELFARE BENEFITS PLAN 2018 401k membership
Total participants, beginning-of-year	2018-04-01	289
Total number of active participants reported on line 7a of the Form 5500	2018-04-01	297
Number of retired or separated participants receiving benefits	2018-04-01	4
Total of all active and inactive participants	2018-04-01	301

Form 5500 Responses for GRAND RIVER MEDICAL GROUP, P.C. WELFARE BENEFITS PLAN

2022: GRAND RIVER MEDICAL GROUP, P.C. WELFARE BENEFITS PLAN 2022 form 5500 responses
2022-01-01	Type of plan entity	Single employer plan
2022-01-01	Plan funding arrangement – Insurance	Yes
2022-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2022-01-01	Plan benefit arrangement – Insurance	Yes
2021: GRAND RIVER MEDICAL GROUP, P.C. WELFARE BENEFITS PLAN 2021 form 5500 responses
2021-01-01	Type of plan entity	Single employer plan
2021-01-01	Plan funding arrangement – Insurance	Yes
2021-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2021-01-01	Plan benefit arrangement – Insurance	Yes
2020: GRAND RIVER MEDICAL GROUP, P.C. WELFARE BENEFITS PLAN 2020 form 5500 responses
2020-01-01	Type of plan entity	Single employer plan
2020-01-01	Plan funding arrangement – Insurance	Yes
2020-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2020-01-01	Plan benefit arrangement – Insurance	Yes
2019: GRAND RIVER MEDICAL GROUP, P.C. WELFARE BENEFITS PLAN 2019 form 5500 responses
2019-01-01	Type of plan entity	Single employer plan
2019-01-01	Plan funding arrangement – Insurance	Yes
2019-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2019-01-01	Plan benefit arrangement – Insurance	Yes
2018: GRAND RIVER MEDICAL GROUP, P.C. WELFARE BENEFITS PLAN 2018 form 5500 responses
2018-04-01	Type of plan entity	Single employer plan
2018-04-01	First time form 5500 has been submitted	Yes
2018-04-01	This return/report is a short plan year return/report (less than 12 months)	Yes
2018-04-01	Plan funding arrangement – Insurance	Yes
2018-04-01	Plan funding arrangement – General assets of the sponsor	Yes
2018-04-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

LTD 124338

Policy instance

Insurance contract or identification number	LTD 124338
Number of Individuals Covered	313
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $5,077
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $103,890
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,077
Insurance broker organization code?	3

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

GL 154747

Policy instance

Insurance contract or identification number	GL 154747
Number of Individuals Covered	153
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $8,702
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $58,016
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,702
Insurance broker organization code?	3

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

GL 151585

Policy instance

Insurance contract or identification number	GL 151585
Number of Individuals Covered	314
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $2,569
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $37,823
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,569
Insurance broker organization code?	3

VERATRUS BUSINESS SOLUTIONS (National Association of Insurance Commissioners NAIC id number: 13742 )

Policy contract number

35232

Policy instance

Insurance contract or identification number	35232
Number of Individuals Covered	131
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $2,449
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $24,488
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,449
Insurance broker organization code?	3

DELTA DENTAL OF IOWA (National Association of Insurance Commissioners NAIC id number: 55786 )

Policy contract number

35232

Policy instance

Insurance contract or identification number	35232
Number of Individuals Covered	243
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $8,450
Total amount of fees paid to insurance company	USD $1,180
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $255,804
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,450
Amount paid for insurance broker fees	1180
Additional information about fees paid to insurance broker	SALES AND PERSISTENCY BONUS
Insurance broker organization code?	3

WELLMARK HEALTH PLAN OF IOWA (National Association of Insurance Commissioners NAIC id number: 95531 )

Policy contract number

956

Policy instance

Insurance contract or identification number	956
Number of Individuals Covered	225
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $45,135
Total amount of fees paid to insurance company	USD $0
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 $45,135
Insurance broker organization code?	3

WELLMARK HEALTH PLAN OF IOWA (National Association of Insurance Commissioners NAIC id number: 95531 )

Policy contract number

956

Policy instance

Insurance contract or identification number	956
Number of Individuals Covered	221
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $45,650
Total amount of fees paid to insurance company	USD $0
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 $45,650
Insurance broker organization code?	3

DELTA DENTAL OF IOWA (National Association of Insurance Commissioners NAIC id number: 55786 )

Policy contract number

35232

Policy instance

Insurance contract or identification number	35232
Number of Individuals Covered	232
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $8,098
Total amount of fees paid to insurance company	USD $1,110
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $238,155
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,098
Amount paid for insurance broker fees	1110
Additional information about fees paid to insurance broker	SALES AND PERSISTENCY BONUS
Insurance broker organization code?	3

VERATRUS BUSINESS SOLUTIONS (National Association of Insurance Commissioners NAIC id number: 13742 )

Policy contract number

35232

Policy instance

Insurance contract or identification number	35232
Number of Individuals Covered	119
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $2,311
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $23,107
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,311
Insurance broker organization code?	3

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

GL 151585

Policy instance

Insurance contract or identification number	GL 151585
Number of Individuals Covered	299
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $2,574
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $37,456
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

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

GL 154747

Policy instance

Insurance contract or identification number	GL 154747
Number of Individuals Covered	154
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $9,612
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $64,077
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,612
Insurance broker organization code?	3

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

LTD 124338

Policy instance

Insurance contract or identification number	LTD 124338
Number of Individuals Covered	301
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $5,147
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $102,451
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,147
Insurance broker organization code?	3

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

LTD 124338

Policy instance

Insurance contract or identification number	LTD 124338
Number of Individuals Covered	283
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $5,038
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $95,017
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,038
Insurance broker organization code?	3

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

GL 154747

Policy instance

Insurance contract or identification number	GL 154747
Number of Individuals Covered	146
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $10,304
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $68,693
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,304
Insurance broker organization code?	3

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

GL 151585

Policy instance

Insurance contract or identification number	GL 151585
Number of Individuals Covered	282
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $2,464
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $34,767
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,464
Insurance broker organization code?	3

VERATRUS BUSINESS SOLUTIONS (National Association of Insurance Commissioners NAIC id number: 13742 )

Policy contract number

35232

Policy instance

Insurance contract or identification number	35232
Number of Individuals Covered	107
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $1,996
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $17,448
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,996
Insurance broker organization code?	3

DELTA DENTAL OF IOWA (National Association of Insurance Commissioners NAIC id number: 55786 )

Policy contract number

35232

Policy instance

Insurance contract or identification number	35232
Number of Individuals Covered	224
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $7,868
Total amount of fees paid to insurance company	USD $1,374
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $198,191
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,868
Amount paid for insurance broker fees	1374
Additional information about fees paid to insurance broker	SALES AND PERSISTENCY BONUS
Insurance broker organization code?	3

WELLMARK HEALTH PLAN OF IOWA (National Association of Insurance Commissioners NAIC id number: 95531 )

Policy contract number

956

Policy instance

Insurance contract or identification number	956
Number of Individuals Covered	223
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $51,597
Total amount of fees paid to insurance company	USD $0
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 $51,597
Insurance broker organization code?	3

WELLMARK HEALTH PLAN OF IOWA (National Association of Insurance Commissioners NAIC id number: 95531 )

Policy contract number

956

Policy instance

Insurance contract or identification number	956
Number of Individuals Covered	214
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $51,070
Total amount of fees paid to insurance company	USD $0
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 $51,070
Insurance broker organization code?	3

DELTA DENTAL OF IOWA (National Association of Insurance Commissioners NAIC id number: 55786 )

Policy contract number

35232

Policy instance

Insurance contract or identification number	35232
Number of Individuals Covered	216
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $7,710
Total amount of fees paid to insurance company	USD $1,574
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $237,584
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,710
Amount paid for insurance broker fees	1574
Additional information about fees paid to insurance broker	SALES AND PERSISTENCY BONUS
Insurance broker organization code?	3

VERATRUS BUSINESS SOLUTIONS (National Association of Insurance Commissioners NAIC id number: 13742 )

Policy contract number

35232

Policy instance

Insurance contract or identification number	35232
Number of Individuals Covered	98
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $1,787
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $19,545
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,787
Insurance broker organization code?	3

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

GL 151585

Policy instance

Insurance contract or identification number	GL 151585
Number of Individuals Covered	291
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $2,355
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $32,475
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,355
Insurance broker organization code?	3

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

GL 154747

Policy instance

Insurance contract or identification number	GL 154747
Number of Individuals Covered	152
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $9,008
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $60,054
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,008
Insurance broker organization code?	3

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

LTD 124338

Policy instance

Insurance contract or identification number	LTD 124338
Number of Individuals Covered	292
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $4,949
Total amount of fees paid to insurance company	USD $0
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $88,713
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,949
Insurance broker organization code?	3

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

LTD 124338

Policy instance

Insurance contract or identification number	LTD 124338
Number of Individuals Covered	288
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $5,284
Total amount of fees paid to insurance company	USD $1,173
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $94,813
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,284
Amount paid for insurance broker fees	1173
Additional information about fees paid to insurance broker	ADMINISTRATIVE
Insurance broker organization code?	3

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

GL 154747

Policy instance

Insurance contract or identification number	GL 154747
Number of Individuals Covered	150
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $8,610
Total amount of fees paid to insurance company	USD $644
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $57,401
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,610
Amount paid for insurance broker fees	644
Additional information about fees paid to insurance broker	ADMINISTRATIVE
Insurance broker organization code?	3

RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )

Policy contract number

GL 151585

Policy instance

Insurance contract or identification number	GL 151585
Number of Individuals Covered	289
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $2,539
Total amount of fees paid to insurance company	USD $442
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $35,401
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,539
Amount paid for insurance broker fees	442
Additional information about fees paid to insurance broker	ADMINISTRATIVE
Insurance broker organization code?	3

VERATRUS BUSINESS SOLUTIONS (National Association of Insurance Commissioners NAIC id number: 13742 )

Policy contract number

35232

Policy instance

Insurance contract or identification number	35232
Number of Individuals Covered	102
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $1,779
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $17,793
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,779
Insurance broker organization code?	3

DELTA DENTAL OF IOWA (National Association of Insurance Commissioners NAIC id number: 55786 )

Policy contract number

35232

Policy instance

Insurance contract or identification number	35232
Number of Individuals Covered	228
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $7,381
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $202,195
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,381
Insurance broker organization code?	3

WELLMARK HEALTH PLAN OF IOWA (National Association of Insurance Commissioners NAIC id number: 95531 )

Policy contract number

956

Policy instance

Insurance contract or identification number	956
Number of Individuals Covered	225
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $52,880
Total amount of fees paid to insurance company	USD $0
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 $52,880
Insurance broker organization code?	3

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Company Name:	DUBUQUE INTERNAL MEDICINE PC DBA GRAND RIVER MEDICAL GROUP
Employer identification number (EIN):	420848123
NAIC Classification:	621111
NAIC Description:	Offices of Physicians (except Mental Health Specialists)