KNOXVILLE COMMUNITY HOSPITAL has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan KNOXVILLE COMMUNITY HOSPITAL INC. EMPLOYEE BENEFIT PLAN
401k plan membership statisitcs for KNOXVILLE COMMUNITY HOSPITAL INC. EMPLOYEE BENEFIT PLAN
| Measure | Date | Value |
|---|
| 2023: KNOXVILLE COMMUNITY HOSPITAL INC. EMPLOYEE BENEFIT PLAN 2023 401k membership |
|---|
| Total participants, beginning-of-year | 2023-01-01 | 197 |
| Total number of active participants reported on line 7a of the Form 5500 | 2023-01-01 | 290 |
| Number of retired or separated participants receiving benefits | 2023-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2023-01-01 | 0 |
| Total of all active and inactive participants | 2023-01-01 | 290 |
| Number of employers contributing to the scheme | 2023-01-01 | 0 |
| 2022: KNOXVILLE COMMUNITY HOSPITAL INC. EMPLOYEE BENEFIT PLAN 2022 401k membership |
|---|
| Total participants, beginning-of-year | 2022-01-01 | 190 |
| Total number of active participants reported on line 7a of the Form 5500 | 2022-01-01 | 197 |
| Number of retired or separated participants receiving benefits | 2022-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2022-01-01 | 0 |
| Total of all active and inactive participants | 2022-01-01 | 197 |
| Number of employers contributing to the scheme | 2022-01-01 | 0 |
| 2021: KNOXVILLE COMMUNITY HOSPITAL INC. EMPLOYEE BENEFIT PLAN 2021 401k membership |
|---|
| Total participants, beginning-of-year | 2021-01-01 | 190 |
| Total number of active participants reported on line 7a of the Form 5500 | 2021-01-01 | 190 |
| Number of retired or separated participants receiving benefits | 2021-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2021-01-01 | 0 |
| Total of all active and inactive participants | 2021-01-01 | 190 |
| Number of employers contributing to the scheme | 2021-01-01 | 0 |
| 2020: KNOXVILLE COMMUNITY HOSPITAL INC. EMPLOYEE BENEFIT PLAN 2020 401k membership |
|---|
| Total participants, beginning-of-year | 2020-01-01 | 198 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-01-01 | 190 |
| Number of retired or separated participants receiving benefits | 2020-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2020-01-01 | 0 |
| Total of all active and inactive participants | 2020-01-01 | 190 |
| Number of employers contributing to the scheme | 2020-01-01 | 0 |
| 2019: KNOXVILLE COMMUNITY HOSPITAL INC. EMPLOYEE BENEFIT PLAN 2019 401k membership |
|---|
| Total participants, beginning-of-year | 2019-01-01 | 193 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-01-01 | 198 |
| Number of retired or separated participants receiving benefits | 2019-01-01 | 2 |
| Number of other retired or separated participants entitled to future benefits | 2019-01-01 | 0 |
| Total of all active and inactive participants | 2019-01-01 | 200 |
| 2018: KNOXVILLE COMMUNITY HOSPITAL INC. EMPLOYEE BENEFIT PLAN 2018 401k membership |
|---|
| Total participants, beginning-of-year | 2018-01-01 | 192 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-01-01 | 193 |
| Number of retired or separated participants receiving benefits | 2018-01-01 | 3 |
| Number of other retired or separated participants entitled to future benefits | 2018-01-01 | 0 |
| Total of all active and inactive participants | 2018-01-01 | 196 |
| 2017: KNOXVILLE COMMUNITY HOSPITAL INC. EMPLOYEE BENEFIT PLAN 2017 401k membership |
|---|
| Total participants, beginning-of-year | 2017-01-01 | 182 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-01-01 | 191 |
| Number of retired or separated participants receiving benefits | 2017-01-01 | 2 |
| Number of other retired or separated participants entitled to future benefits | 2017-01-01 | 0 |
| Total of all active and inactive participants | 2017-01-01 | 193 |
| 2016: KNOXVILLE COMMUNITY HOSPITAL INC. EMPLOYEE BENEFIT PLAN 2016 401k membership |
|---|
| Total participants, beginning-of-year | 2016-01-01 | 186 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-01-01 | 182 |
| Number of retired or separated participants receiving benefits | 2016-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2016-01-01 | 0 |
| Total of all active and inactive participants | 2016-01-01 | 182 |
| 2015: KNOXVILLE COMMUNITY HOSPITAL INC. EMPLOYEE BENEFIT PLAN 2015 401k membership |
|---|
| Total participants, beginning-of-year | 2015-01-01 | 148 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-01-01 | 186 |
| Number of retired or separated participants receiving benefits | 2015-01-01 | 1 |
| Number of other retired or separated participants entitled to future benefits | 2015-01-01 | 0 |
| Total of all active and inactive participants | 2015-01-01 | 187 |
| 2014: KNOXVILLE COMMUNITY HOSPITAL INC. EMPLOYEE BENEFIT PLAN 2014 401k membership |
|---|
| Total participants, beginning-of-year | 2014-01-01 | 148 |
| Total number of active participants reported on line 7a of the Form 5500 | 2014-01-01 | 148 |
| Number of retired or separated participants receiving benefits | 2014-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2014-01-01 | 0 |
| Total of all active and inactive participants | 2014-01-01 | 148 |
| Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits | 2014-01-01 | 0 |
| Total participants | 2014-01-01 | 148 |
| Number of participants with account balances | 2014-01-01 | 0 |
| Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested | 2014-01-01 | 0 |
| 2013: KNOXVILLE COMMUNITY HOSPITAL INC. EMPLOYEE BENEFIT PLAN 2013 401k membership |
|---|
| Total participants, beginning-of-year | 2013-01-01 | 64 |
| Total number of active participants reported on line 7a of the Form 5500 | 2013-01-01 | 56 |
| Number of retired or separated participants receiving benefits | 2013-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2013-01-01 | 0 |
| Total of all active and inactive participants | 2013-01-01 | 56 |
| 2012: KNOXVILLE COMMUNITY HOSPITAL INC. EMPLOYEE BENEFIT PLAN 2012 401k membership |
|---|
| Total participants, beginning-of-year | 2012-01-01 | 141 |
| Total number of active participants reported on line 7a of the Form 5500 | 2012-01-01 | 152 |
| Number of retired or separated participants receiving benefits | 2012-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2012-01-01 | 0 |
| Total of all active and inactive participants | 2012-01-01 | 152 |
| 2011: KNOXVILLE COMMUNITY HOSPITAL INC. EMPLOYEE BENEFIT PLAN 2011 401k membership |
|---|
| Total participants, beginning-of-year | 2011-01-01 | 141 |
| Total number of active participants reported on line 7a of the Form 5500 | 2011-01-01 | 146 |
| Number of retired or separated participants receiving benefits | 2011-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2011-01-01 | 0 |
| Total of all active and inactive participants | 2011-01-01 | 146 |
| 2010: KNOXVILLE COMMUNITY HOSPITAL INC. EMPLOYEE BENEFIT PLAN 2010 401k membership |
|---|
| Total participants, beginning-of-year | 2010-01-01 | 160 |
| Total number of active participants reported on line 7a of the Form 5500 | 2010-01-01 | 151 |
| Number of retired or separated participants receiving benefits | 2010-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2010-01-01 | 0 |
| Total of all active and inactive participants | 2010-01-01 | 151 |
| 2009: KNOXVILLE COMMUNITY HOSPITAL INC. EMPLOYEE BENEFIT PLAN 2009 401k membership |
|---|
| Total participants, beginning-of-year | 2009-07-01 | 189 |
| Total number of active participants reported on line 7a of the Form 5500 | 2009-07-01 | 211 |
| Number of retired or separated participants receiving benefits | 2009-07-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2009-07-01 | 0 |
| Total of all active and inactive participants | 2009-07-01 | 211 |
| Total participants | 2009-07-01 | 211 |
| Total participants, beginning-of-year | 2009-01-01 | 132 |
| Total number of active participants reported on line 7a of the Form 5500 | 2009-01-01 | 156 |
| Number of retired or separated participants receiving benefits | 2009-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2009-01-01 | 0 |
| Total of all active and inactive participants | 2009-01-01 | 156 |
| 2023: KNOXVILLE COMMUNITY HOSPITAL INC. EMPLOYEE BENEFIT PLAN 2023 form 5500 responses |
|---|
| 2023-01-01 | Type of plan entity | Single employer plan |
| 2023-01-01 | Plan funding arrangement – Insurance | Yes |
| 2023-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2023-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2023-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2022: KNOXVILLE COMMUNITY HOSPITAL INC. EMPLOYEE BENEFIT 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 |
| 2022-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2021: KNOXVILLE COMMUNITY HOSPITAL INC. EMPLOYEE BENEFIT 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 |
| 2021-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2020: KNOXVILLE COMMUNITY HOSPITAL INC. EMPLOYEE BENEFIT 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 benefit arrangement – Insurance | Yes |
| 2019: KNOXVILLE COMMUNITY HOSPITAL INC. EMPLOYEE BENEFIT PLAN 2019 form 5500 responses |
|---|
| 2019-01-01 | Type of plan entity | Single employer plan |
| 2019-01-01 | Submission has been amended | No |
| 2019-01-01 | This submission is the final filing | No |
| 2019-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2019-01-01 | Plan is a collectively bargained plan | No |
| 2019-01-01 | Plan funding arrangement – Insurance | Yes |
| 2019-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2018: KNOXVILLE COMMUNITY HOSPITAL INC. EMPLOYEE BENEFIT PLAN 2018 form 5500 responses |
|---|
| 2018-01-01 | Type of plan entity | Single employer plan |
| 2018-01-01 | Submission has been amended | No |
| 2018-01-01 | This submission is the final filing | No |
| 2018-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2018-01-01 | Plan is a collectively bargained plan | No |
| 2018-01-01 | Plan funding arrangement – Insurance | Yes |
| 2018-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2017: KNOXVILLE COMMUNITY HOSPITAL INC. EMPLOYEE BENEFIT PLAN 2017 form 5500 responses |
|---|
| 2017-01-01 | Type of plan entity | Single employer plan |
| 2017-01-01 | Submission has been amended | No |
| 2017-01-01 | This submission is the final filing | No |
| 2017-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2017-01-01 | Plan is a collectively bargained plan | No |
| 2017-01-01 | Plan funding arrangement – Insurance | Yes |
| 2017-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2016: KNOXVILLE COMMUNITY HOSPITAL INC. EMPLOYEE BENEFIT PLAN 2016 form 5500 responses |
|---|
| 2016-01-01 | Type of plan entity | Single employer plan |
| 2016-01-01 | Submission has been amended | No |
| 2016-01-01 | This submission is the final filing | No |
| 2016-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2016-01-01 | Plan is a collectively bargained plan | No |
| 2016-01-01 | Plan funding arrangement – Insurance | Yes |
| 2016-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2015: KNOXVILLE COMMUNITY HOSPITAL INC. EMPLOYEE BENEFIT PLAN 2015 form 5500 responses |
|---|
| 2015-01-01 | Type of plan entity | Single employer plan |
| 2015-01-01 | Submission has been amended | No |
| 2015-01-01 | This submission is the final filing | No |
| 2015-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2015-01-01 | Plan is a collectively bargained plan | No |
| 2015-01-01 | Plan funding arrangement – Insurance | Yes |
| 2015-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2014: KNOXVILLE COMMUNITY HOSPITAL INC. EMPLOYEE BENEFIT PLAN 2014 form 5500 responses |
|---|
| 2014-01-01 | Type of plan entity | Single employer plan |
| 2014-01-01 | Submission has been amended | No |
| 2014-01-01 | This submission is the final filing | No |
| 2014-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2014-01-01 | Plan is a collectively bargained plan | No |
| 2014-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2014-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2013: KNOXVILLE COMMUNITY HOSPITAL INC. EMPLOYEE BENEFIT PLAN 2013 form 5500 responses |
|---|
| 2013-01-01 | Type of plan entity | Single employer plan |
| 2013-01-01 | Submission has been amended | No |
| 2013-01-01 | This submission is the final filing | No |
| 2013-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2013-01-01 | Plan is a collectively bargained plan | No |
| 2013-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2013-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2012: KNOXVILLE COMMUNITY HOSPITAL INC. EMPLOYEE BENEFIT PLAN 2012 form 5500 responses |
|---|
| 2012-01-01 | Type of plan entity | Single employer plan |
| 2012-01-01 | Submission has been amended | No |
| 2012-01-01 | This submission is the final filing | No |
| 2012-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2012-01-01 | Plan is a collectively bargained plan | No |
| 2012-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2012-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2011: KNOXVILLE COMMUNITY HOSPITAL INC. EMPLOYEE BENEFIT PLAN 2011 form 5500 responses |
|---|
| 2011-01-01 | Type of plan entity | Single employer plan |
| 2011-01-01 | Submission has been amended | No |
| 2011-01-01 | This submission is the final filing | No |
| 2011-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2011-01-01 | Plan is a collectively bargained plan | No |
| 2011-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2011-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2010: KNOXVILLE COMMUNITY HOSPITAL INC. EMPLOYEE BENEFIT PLAN 2010 form 5500 responses |
|---|
| 2010-01-01 | Type of plan entity | Single employer plan |
| 2010-01-01 | Submission has been amended | No |
| 2010-01-01 | This submission is the final filing | No |
| 2010-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2010-01-01 | Plan is a collectively bargained plan | No |
| 2010-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2010-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2009: KNOXVILLE COMMUNITY HOSPITAL INC. EMPLOYEE BENEFIT PLAN 2009 form 5500 responses |
|---|
| 2009-07-01 | Type of plan entity | Single employer plan |
| 2009-07-01 | Submission has been amended | No |
| 2009-07-01 | This submission is the final filing | No |
| 2009-07-01 | This return/report is a short plan year return/report (less than 12 months) | Yes |
| 2009-07-01 | Plan is a collectively bargained plan | No |
| 2009-07-01 | Plan funding arrangement – Insurance | Yes |
| 2009-07-01 | Plan benefit arrangement – Insurance | Yes |
| 2009-01-01 | Type of plan entity | Single employer plan |
| 2009-01-01 | Submission has been amended | No |
| 2009-01-01 | This submission is the final filing | No |
| 2009-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2009-01-01 | Plan is a collectively bargained plan | No |
| 2009-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2009-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 30094339 |
| Policy instance | 3 |
| Insurance contract or identification number | 30094339 | | Number of Individuals Covered | 126 | | Insurance policy start date | 2023-01-01 | | Insurance policy end date | 2023-12-31 | | Total amount of commissions paid to insurance broker | USD $1,019 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $16,605 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| WELLMARK HEALTH PLAN OF IOWA (National Association of Insurance Commissioners NAIC id number: 95531 ) |
| Policy contract number | 16367 |
| Policy instance | 8 |
| Insurance contract or identification number | 16367 | | Number of Individuals Covered | 156 | | Insurance policy start date | 2023-01-01 | | Insurance policy end date | 2023-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Welfare Benefit Premiums Paid to Carrier | USD $2,547,726 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| DELTA DENTAL OF IOWA (National Association of Insurance Commissioners NAIC id number: 55786 ) |
| Policy contract number | 33179 |
| Policy instance | 1 |
| Insurance contract or identification number | 33179 | | Number of Individuals Covered | 156 | | Insurance policy start date | 2023-01-01 | | Insurance policy end date | 2023-12-31 | | Total amount of commissions paid to insurance broker | USD $6,519 | | Total amount of fees paid to insurance company | USD $665 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $149,621 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 ) |
| Policy contract number | 1040434 |
| Policy instance | 2 |
| Insurance contract or identification number | 1040434 | | Number of Individuals Covered | 24 | | Insurance policy start date | 2023-01-01 | | Insurance policy end date | 2023-12-31 | | Total amount of commissions paid to insurance broker | USD $8,622 | | Total amount of fees paid to insurance company | USD $1,019 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $40,496 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| UNITED HEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 00 |
| Policy instance | 4 |
| Insurance contract or identification number | 00 | | Number of Individuals Covered | 290 | | Insurance policy start date | 2023-01-01 | | Insurance policy end date | 2023-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | EMPLOYEE ASSISTANCE PROGRAM | | Welfare Benefit Premiums Paid to Carrier | USD $6,090 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| ASSURITY LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71439 ) |
| Policy contract number | 0800000582 |
| Policy instance | 5 |
| Insurance contract or identification number | 0800000582 | | Number of Individuals Covered | 29 | | Insurance policy start date | 2023-01-01 | | Insurance policy end date | 2023-12-31 | | Total amount of commissions paid to insurance broker | USD $1,314 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | CRITICAL ILLNESS | | Welfare Benefit Premiums Paid to Carrier | USD $12,335 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| UNITED HEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | P007004393 |
| Policy instance | 6 |
| Insurance contract or identification number | P007004393 | | Number of Individuals Covered | 13 | | Insurance policy start date | 2023-01-01 | | Insurance policy end date | 2023-12-31 | | Total amount of commissions paid to insurance broker | USD $217 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $5,969 | | 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 number | GL652315 |
| Policy instance | 7 |
| Insurance contract or identification number | GL652315 | | Number of Individuals Covered | 198 | | Insurance policy start date | 2023-01-01 | | Insurance policy end date | 2023-12-31 | | Total amount of commissions paid to insurance broker | USD $28,438 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $194,443 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| DELTA DENTAL OF IOWA (National Association of Insurance Commissioners NAIC id number: 55786 ) |
| Policy contract number | 33179 |
| Policy instance | 1 |
| Insurance contract or identification number | 33179 | | Number of Individuals Covered | 155 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $14,736 | | Total amount of fees paid to insurance company | USD $655 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $134,893 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $14,736 | | Amount paid for insurance broker fees | 655 | | Additional information about fees paid to insurance broker | SALES AND PERSISTENCY BONUS | | Insurance broker organization code? | 3 |
|
| PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 ) |
| Policy contract number | 1040434 |
| Policy instance | 2 |
| Insurance contract or identification number | 1040434 | | Number of Individuals Covered | 17 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $7,267 | | Total amount of fees paid to insurance company | USD $1,153 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $31,436 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,814 | | Amount paid for insurance broker fees | 872 | | Additional information about fees paid to insurance broker | BONUS | | Insurance broker organization code? | 3 |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 30094339 |
| Policy instance | 3 |
| Insurance contract or identification number | 30094339 | | Number of Individuals Covered | 123 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $1,199 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $15,386 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $939 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| UNITED HEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 000000 |
| Policy instance | 4 |
| Insurance contract or identification number | 000000 | | Number of Individuals Covered | 299 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | EMPLOYEE ASSISTANCE PROGRAM | | Welfare Benefit Premiums Paid to Carrier | USD $6,279 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| ASSURITY LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71439 ) |
| Policy contract number | 0800000582 |
| Policy instance | 5 |
| Insurance contract or identification number | 0800000582 | | Number of Individuals Covered | 36 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $1,617 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | CRITICAL ILLNESS | | Welfare Benefit Premiums Paid to Carrier | USD $13,756 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $765 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| UNITED HEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | P007004393 |
| Policy instance | 6 |
| Insurance contract or identification number | P007004393 | | Number of Individuals Covered | 15 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $552 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $6,187 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $352 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| WELLMARK HEALTH PLAN OF IOWA (National Association of Insurance Commissioners NAIC id number: 95531 ) |
| Policy contract number | 16367 |
| Policy instance | 8 |
| Insurance contract or identification number | 16367 | | Number of Individuals Covered | 158 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Welfare Benefit Premiums Paid to Carrier | USD $2,287,374 | | 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 number | GL652315 |
| Policy instance | 7 |
| Insurance contract or identification number | GL652315 | | Number of Individuals Covered | 197 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $20,291 | | Total amount of fees paid to insurance company | USD $4,409 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $180,734 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $18,595 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Additional information about fees paid to insurance broker | ADMINISTRATIVE AND OTHER FEES |
|
| DELTA DENTAL OF IOWA (National Association of Insurance Commissioners NAIC id number: 55786 ) |
| Policy contract number | 33179 |
| Policy instance | 1 |
| Insurance contract or identification number | 33179 | | Number of Individuals Covered | 157 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $14,816 | | Total amount of fees paid to insurance company | USD $638 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $160,372 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $14,816 | | Amount paid for insurance broker fees | 638 | | Additional information about fees paid to insurance broker | SALES AND PERSISTENCY BONUS | | Insurance broker organization code? | 3 |
|
| PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 ) |
| Policy contract number | 1040434 |
| Policy instance | 2 |
| Insurance contract or identification number | 1040434 | | Number of Individuals Covered | 17 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $6,400 | | Total amount of fees paid to insurance company | USD $903 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $26,844 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,400 | | Amount paid for insurance broker fees | 773 | | Additional information about fees paid to insurance broker | BONUS | | Insurance broker organization code? | 3 |
|
| WELLMARK BLUE CROSS BLUE SHIELD OF SOUTH DAKOTA (National Association of Insurance Commissioners NAIC id number: 88848 ) |
| Policy contract number | 16367 |
| Policy instance | 3 |
| Insurance contract or identification number | 16367 | | Number of Individuals Covered | 5 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $59,197 | | 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 number | 30094339 |
| Policy instance | 4 |
| Insurance contract or identification number | 30094339 | | Number of Individuals Covered | 111 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $873 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $14,609 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $873 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| WELLMARK HEALTH PLAN OF IOWA (National Association of Insurance Commissioners NAIC id number: 95531 ) |
| Policy contract number | 16367 |
| Policy instance | 5 |
| Insurance contract or identification number | 16367 | | Number of Individuals Covered | 160 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $2,171,971 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| EMPLOYEE & FAMILY RESOURCES, INC. (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 000000 |
| Policy instance | 6 |
| Insurance contract or identification number | 000000 | | Number of Individuals Covered | 215 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | EMPLOYEE ASSISTANCE PROGRAM | | Welfare Benefit Premiums Paid to Carrier | USD $4,515 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| ASSURITY LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71439 ) |
| Policy contract number | 0800000582 |
| Policy instance | 7 |
| Insurance contract or identification number | 0800000582 | | Number of Individuals Covered | 45 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $3,913 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | CRITICAL ILLNESS | | Welfare Benefit Premiums Paid to Carrier | USD $17,671 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $3,913 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| UNITED HEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | SB 7004393 |
| Policy instance | 8 |
| Insurance contract or identification number | SB 7004393 | | Number of Individuals Covered | 19 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $1,328 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $8,656 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $784 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | GL652315 |
| Policy instance | 9 |
| Insurance contract or identification number | GL652315 | | Number of Individuals Covered | 193 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $20,498 | | Total amount of fees paid to insurance company | USD $1,174 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $178,643 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $20,498 | | Amount paid for insurance broker fees | 1174 | | Additional information about fees paid to insurance broker | ADMINISTRATIVE AND OTHER FEES | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL OF IOWA (National Association of Insurance Commissioners NAIC id number: 55786 ) |
| Policy contract number | 33179 |
| Policy instance | 1 |
| Insurance contract or identification number | 33179 | | Number of Individuals Covered | 158 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $14,966 | | Total amount of fees paid to insurance company | USD $690 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $143,378 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $14,966 | | Amount paid for insurance broker fees | 690 | | Additional information about fees paid to insurance broker | SALES AND PERSISTENCY BONUS | | Insurance broker organization code? | 3 |
|
| PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 ) |
| Policy contract number | 1040434 |
| Policy instance | 2 |
| Insurance contract or identification number | 1040434 | | Number of Individuals Covered | 17 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $5,156 | | Total amount of fees paid to insurance company | USD $469 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $25,969 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,156 | | Amount paid for insurance broker fees | 469 | | Additional information about fees paid to insurance broker | BONUS | | Insurance broker organization code? | 3 |
|
| WELLMARK BLUE CROSS BLUE SHIELD OF SOUTH DAKOTA (National Association of Insurance Commissioners NAIC id number: 88848 ) |
| Policy contract number | 16367 |
| Policy instance | 3 |
| Insurance contract or identification number | 16367 | | Number of Individuals Covered | 12 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $188,663 | | 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 number | 30094339 |
| Policy instance | 4 |
| Insurance contract or identification number | 30094339 | | 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 $891 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $13,957 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $648 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| WELLMARK HEALTH PLAN OF IOWA (National Association of Insurance Commissioners NAIC id number: 95531 ) |
| Policy contract number | 16367 |
| Policy instance | 5 |
| Insurance contract or identification number | 16367 | | Number of Individuals Covered | 155 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,949,993 | | 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 number | GL652315 |
| Policy instance | 6 |
| Insurance contract or identification number | GL652315 | | Number of Individuals Covered | 190 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $7,825 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $52,168 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,825 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | VAR 658426 |
| Policy instance | 1 |
| Insurance contract or identification number | VAR 658426 | | Number of Individuals Covered | 89 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $382 | | Total amount of fees paid to insurance company | USD $64 | | Other welfare benefits provided | VOLUNTARY ACCIDENTAL DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $2,544 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $382 | | Amount paid for insurance broker fees | 64 | | Additional information about fees paid to insurance broker | TOTAL ADMINISTRATIVE AND OTHER FEES | | Insurance broker organization code? | 3 |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | GL 652297 |
| Policy instance | 2 |
| Insurance contract or identification number | GL 652297 | | Number of Individuals Covered | 102 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $6,190 | | Total amount of fees paid to insurance company | USD $965 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $41,267 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,190 | | Amount paid for insurance broker fees | 965 | | Additional information about fees paid to insurance broker | TOTAL ADMINISTRATIVE AND OTHER FEES | | Insurance broker organization code? | 3 |
|
| WELLMARK HEALTH PLAN OF IOWA (National Association of Insurance Commissioners NAIC id number: 95531 ) |
| Policy contract number | 00016367 |
| Policy instance | 3 |
| Insurance contract or identification number | 00016367 | | Number of Individuals Covered | 149 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,888,546 | | 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 number | GL 652315 |
| Policy instance | 4 |
| Insurance contract or identification number | GL 652315 | | Number of Individuals Covered | 198 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $1,635 | | Total amount of fees paid to insurance company | USD $248 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $10,900 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,635 | | Amount paid for insurance broker fees | 248 | | Additional information about fees paid to insurance broker | TOTAL ADMINISTRATIVE AND OTHER FEES | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL OF IOWA (National Association of Insurance Commissioners NAIC id number: 55786 ) |
| Policy contract number | 33179 |
| Policy instance | 5 |
| Insurance contract or identification number | 33179 | | Number of Individuals Covered | 153 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $14,574 | | Total amount of fees paid to insurance company | USD $507 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $146,090 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $14,574 | | Amount paid for insurance broker fees | 507 | | Additional information about fees paid to insurance broker | SALES AND PERSISTENCY BONUS | | Insurance broker organization code? | 3 |
|
| PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 ) |
| Policy contract number | 1031752 |
| Policy instance | 6 |
| Insurance contract or identification number | 1031752 | | Number of Individuals Covered | 159 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $848 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $8,442 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $848 | | Insurance broker organization code? | 3 |
|
| PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 ) |
| Policy contract number | 1040434 |
| Policy instance | 7 |
| Insurance contract or identification number | 1040434 | | Number of Individuals Covered | 16 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $5,069 | | Total amount of fees paid to insurance company | USD $211 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $25,445 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,069 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 211 | | Additional information about fees paid to insurance broker | BONUS |
|
| WELLMARK BLUE CROSS BLUE SHIELD OF SOUTH DAKOTA (National Association of Insurance Commissioners NAIC id number: 88848 ) |
| Policy contract number | 00016367 |
| Policy instance | 8 |
| Insurance contract or identification number | 00016367 | | Number of Individuals Covered | 8 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $140,134 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| WELLMARK BLUE CROSS BLUE SHIELD OF SOUTH DAKOTA (National Association of Insurance Commissioners NAIC id number: 88848 ) |
| Policy contract number | 00016367 |
| Policy instance | 8 |
| Insurance contract or identification number | 00016367 | | Number of Individuals Covered | 5 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $108,016 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 ) |
| Policy contract number | 1040434 |
| Policy instance | 7 |
| Insurance contract or identification number | 1040434 | | Number of Individuals Covered | 15 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $3,972 | | Total amount of fees paid to insurance company | USD $0 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $19,023 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,972 | | Insurance broker organization code? | 3 |
|
| PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 ) |
| Policy contract number | 1031752 |
| Policy instance | 6 |
| Insurance contract or identification number | 1031752 | | Number of Individuals Covered | 171 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $795 | | Total amount of fees paid to insurance company | USD $73 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $8,742 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $795 | | Amount paid for insurance broker fees | 73 | | Additional information about fees paid to insurance broker | BONUS | | Insurance broker organization code? | 3 |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | VAR 658426 |
| Policy instance | 1 |
| Insurance contract or identification number | VAR 658426 | | Number of Individuals Covered | 94 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $426 | | Total amount of fees paid to insurance company | USD $46 | | Other welfare benefits provided | VOLUNTARY ACCIDENTAL DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $2,837 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $426 | | Amount paid for insurance broker fees | 46 | | Additional information about fees paid to insurance broker | TOTAL ADMINISTRATIVE AND OTHER FEES | | Insurance broker organization code? | 3 |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | GL 652297 |
| Policy instance | 2 |
| Insurance contract or identification number | GL 652297 | | Number of Individuals Covered | 119 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $6,436 | | Total amount of fees paid to insurance company | USD $644 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $42,905 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,436 | | Amount paid for insurance broker fees | 644 | | Additional information about fees paid to insurance broker | TOTAL ADMINISTRATIVE AND OTHER FEES | | Insurance broker organization code? | 3 |
|
| WELLMARK HEALTH PLAN OF IOWA (National Association of Insurance Commissioners NAIC id number: 95531 ) |
| Policy contract number | 00016367 |
| Policy instance | 3 |
| Insurance contract or identification number | 00016367 | | Number of Individuals Covered | 156 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,864,072 | | 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 number | GL 652315 |
| Policy instance | 4 |
| Insurance contract or identification number | GL 652315 | | Number of Individuals Covered | 193 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $1,655 | | Total amount of fees paid to insurance company | USD $160 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $11,034 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,655 | | Amount paid for insurance broker fees | 160 | | Additional information about fees paid to insurance broker | TOTAL ADMINISTRATIVE AND OTHER FEES | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL OF IOWA (National Association of Insurance Commissioners NAIC id number: 55786 ) |
| Policy contract number | 33179 |
| Policy instance | 5 |
| Insurance contract or identification number | 33179 | | Number of Individuals Covered | 159 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $8,564 | | Total amount of fees paid to insurance company | USD $419 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $142,739 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,564 | | Amount paid for insurance broker fees | 419 | | Additional information about fees paid to insurance broker | SALES AND PERSISTENCY BONUS | | Insurance broker organization code? | 3 |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | VAR 658426 |
| Policy instance | 1 |
| Insurance contract or identification number | VAR 658426 | | Number of Individuals Covered | 101 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $457 | | Total amount of fees paid to insurance company | USD $28 | | Other welfare benefits provided | VOLUNTARY ACCIDENTAL DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $3,048 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $456 | | Amount paid for insurance broker fees | 28 | | Additional information about fees paid to insurance broker | TOTAL ADMINISTRATIVE AND OTHER FEES | | Insurance broker organization code? | 3 | | Insurance broker name | HEALTHCARE BENEFIT ALLIANCE CORP. |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | GL 652297 |
| Policy instance | 2 |
| Insurance contract or identification number | GL 652297 | | Number of Individuals Covered | 113 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $6,471 | | Total amount of fees paid to insurance company | USD $371 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $43,137 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,441 | | Amount paid for insurance broker fees | 371 | | Additional information about fees paid to insurance broker | TOTAL ADMINISTRATIVE AND OTHER FEES | | Insurance broker organization code? | 3 | | Insurance broker name | HEALTHCARE BENEFIT ALLIANCE CORP. |
|
| WELLMARK HEALTH PLAN OF IOWA (National Association of Insurance Commissioners NAIC id number: 95531 ) |
| Policy contract number | 00016367 |
| Policy instance | 3 |
| Insurance contract or identification number | 00016367 | | Number of Individuals Covered | 150 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $35 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,598,229 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $35 | | Insurance broker organization code? | 3 | | Insurance broker name | LMC INSURANCE & RISK MANAGEMENT INC |
|
| DELTA DENTAL OF IOWA (National Association of Insurance Commissioners NAIC id number: 55786 ) |
| Policy contract number | 33179 |
| Policy instance | 5 |
| Insurance contract or identification number | 33179 | | Number of Individuals Covered | 150 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $7,911 | | Total amount of fees paid to insurance company | USD $455 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $120,943 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,911 | | Amount paid for insurance broker fees | 455 | | Additional information about fees paid to insurance broker | SALES AND PERSISTENCY BONUS | | Insurance broker organization code? | 3 | | Insurance broker name | LAMAIR-MULOCK-CONDON CO. |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | GL 652315 |
| Policy instance | 4 |
| Insurance contract or identification number | GL 652315 | | Number of Individuals Covered | 191 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $1,594 | | Total amount of fees paid to insurance company | USD $99 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $10,628 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,596 | | Amount paid for insurance broker fees | 99 | | Additional information about fees paid to insurance broker | TOTAL ADMINISTRATIVE AND OTHER FEES | | Insurance broker organization code? | 3 | | Insurance broker name | HEALTHCARE BENEFIT ALLIANCE CORP. |
|
| PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 ) |
| Policy contract number | 1031752 |
| Policy instance | 6 |
| Insurance contract or identification number | 1031752 | | Number of Individuals Covered | 139 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $687 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $7,339 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $687 | | Insurance broker organization code? | 3 | | Insurance broker name | LAMAIR MULOCK CONDON COMPANY |
|
| PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 ) |
| Policy contract number | 1040434 |
| Policy instance | 7 |
| Insurance contract or identification number | 1040434 | | Number of Individuals Covered | 16 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $3,848 | | Total amount of fees paid to insurance company | USD $0 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $20,076 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,848 | | Insurance broker organization code? | 3 | | Insurance broker name | GROUP BENEFITS LTD |
|
| WELLMARK BLUE CROSS BLUE SHIELD OF SOUTH DAKOTA (National Association of Insurance Commissioners NAIC id number: 88848 ) |
| Policy contract number | 00016367 |
| Policy instance | 8 |
| Insurance contract or identification number | 00016367 | | Number of Individuals Covered | 10 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $117,868 | | 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 number | VAR 658426 |
| Policy instance | 1 |
| Insurance contract or identification number | VAR 658426 | | Number of Individuals Covered | 105 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $665 | | Total amount of fees paid to insurance company | USD $24 | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $4,433 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $665 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 24 | | Additional information about fees paid to insurance broker | TOTAL ADMINSTRATIVE AND OTHER FEES | | Insurance broker name | NFP INSURANCE SERVICES INC. |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | GL 652297 |
| Policy instance | 2 |
| Insurance contract or identification number | GL 652297 | | Number of Individuals Covered | 112 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $6,330 | | Total amount of fees paid to insurance company | USD $409 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $42,198 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,330 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 409 | | Additional information about fees paid to insurance broker | TOTAL ADMINISTRATIVE AND OTHER FEES | | Insurance broker name | NFP INSURANCE SERVICES INC. |
|
| WELLMARK HEALTH PLAN OF IOWA (National Association of Insurance Commissioners NAIC id number: 95531 ) |
| Policy contract number | 00016367 |
| Policy instance | 3 |
| Insurance contract or identification number | 00016367 | | Number of Individuals Covered | 145 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $49,414 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,522,334 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $49,414 | | Insurance broker organization code? | 3 | | Insurance broker name | LMC INSURANCE & RISK MANAGEMENT INC |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | GL 652315 |
| Policy instance | 4 |
| Insurance contract or identification number | GL 652315 | | Number of Individuals Covered | 186 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $1,640 | | Total amount of fees paid to insurance company | USD $120 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $10,920 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,640 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 120 | | Additional information about fees paid to insurance broker | TOTAL ADMINISTRATIVE AND OTHER FEES | | Insurance broker name | NFP INSURANCE SERVICES INC. |
|
| DELTA DENTAL OF IOWA (National Association of Insurance Commissioners NAIC id number: 55786 ) |
| Policy contract number | 902 |
| Policy instance | 5 |
| Insurance contract or identification number | 902 | | Number of Individuals Covered | 151 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $7,395 | | Total amount of fees paid to insurance company | USD $1,188 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $123,148 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,395 | | Amount paid for insurance broker fees | 1188 | | Additional information about fees paid to insurance broker | FEES PAID | | Insurance broker organization code? | 3 | | Insurance broker name | LAMAIR MULOCK CONDON CO. |
|
| PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 ) |
| Policy contract number | 1031752 |
| Policy instance | 6 |
| Insurance contract or identification number | 1031752 | | Number of Individuals Covered | 184 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $791 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $8,656 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $791 | | Insurance broker organization code? | 3 | | Insurance broker name | LAMAIR MULOCK CONDON COMPANY |
|
| WELLMARK BLUE CROSS BLUE SHIELD OF SOUTH DAKOTA (National Association of Insurance Commissioners NAIC id number: 88848 ) |
| Policy contract number | 00016367 |
| Policy instance | 7 |
| Insurance contract or identification number | 00016367 | | Number of Individuals Covered | 3 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $1,515 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $40,643 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,515 | | Insurance broker organization code? | 3 | | Insurance broker name | LMC INSURANCE & RISK MANAGEMENT INC |
|
| WELLMARK BLUE CROSS BLUE SHIELD OF SOUTH DAKOTA (National Association of Insurance Commissioners NAIC id number: 88848 ) |
| Policy contract number | 00016367 |
| Policy instance | 1 |
| Insurance contract or identification number | 00016367 | | Number of Individuals Covered | 5 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $2,036 | | Total amount of fees paid to insurance company | USD $70,752 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No |
|
| WELLMARK HEALTH PLAN OF IOWA (National Association of Insurance Commissioners NAIC id number: 95531 ) |
| Policy contract number | 00016367 |
| Policy instance | 2 |
| Insurance contract or identification number | 00016367 | | Number of Individuals Covered | 148 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $44,162 | | Total amount of fees paid to insurance company | USD $1,394,225 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | GL 652315 |
| Policy instance | 4 |
| Insurance contract or identification number | GL 652315 | | Number of Individuals Covered | 166 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $1,443 | | Total amount of fees paid to insurance company | USD $9,620 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | VAR 658426 |
| Policy instance | 5 |
| Insurance contract or identification number | VAR 658426 | | Number of Individuals Covered | 70 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $290 | | Total amount of fees paid to insurance company | USD $1,935 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No |
|
| PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 ) |
| Policy contract number | 1031752 |
| Policy instance | 6 |
| Insurance contract or identification number | 1031752 | | Number of Individuals Covered | 171 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $818 | | Total amount of fees paid to insurance company | USD $8,167 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No |
|
| DELTA DENTAL OF IOWA (National Association of Insurance Commissioners NAIC id number: 55786 ) |
| Policy contract number | 902 |
| Policy instance | 7 |
| Insurance contract or identification number | 902 | | Number of Individuals Covered | 150 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $7,174 | | Total amount of fees paid to insurance company | USD $119,563 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | GL 652297 |
| Policy instance | 3 |
| Insurance contract or identification number | GL 652297 | | Number of Individuals Covered | 97 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $4,912 | | Total amount of fees paid to insurance company | USD $32,710 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No |
|
| RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 ) |
| Policy contract number | GL 652297 |
| Policy instance | 5 |
| Insurance contract or identification number | GL 652297 | | Number of Individuals Covered | 85 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $4,478 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $29,856 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| WELLMARK BLUE CROSS BLUE SHIELD OF SOUTH DAKOTA (National Association of Insurance Commissioners NAIC id number: 88848 ) |
| Policy contract number | 00016367 |
| Policy instance | 1 |
| Insurance contract or identification number | 00016367 | | Number of Individuals Covered | 139 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $40,360 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $1,349,844 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| WELLMARK BLUE CROSS BLUE SHIELD OF SOUTH DAKOTA (National Association of Insurance Commissioners NAIC id number: 88848 ) |
| Policy contract number | 00016367 |
| Policy instance | 2 |
| Insurance contract or identification number | 00016367 | | Number of Individuals Covered | 3 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $895 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $30,735 |
|
| DELTA DENTAL OF IOWA (National Association of Insurance Commissioners NAIC id number: 55786 ) |
| Policy contract number | 902 |
| Policy instance | 3 |
| Insurance contract or identification number | 902 | | Number of Individuals Covered | 144 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $7,260 | | Total amount of fees paid to insurance company | USD $844 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $120,992 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 ) |
| Policy contract number | 1031752 |
| Policy instance | 4 |
| Insurance contract or identification number | 1031752 | | Number of Individuals Covered | 174 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $929 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $9,297 | | 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 number | GL 652315 |
| Policy instance | 6 |
| Insurance contract or identification number | GL 652315 | | Number of Individuals Covered | 164 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $1,455 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | GROUP LIFE AND ACCIDENTAL DEATH AND DISMEMBERMENT | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $9,698 | | 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 number | VAR 658426 |
| Policy instance | 7 |
| Insurance contract or identification number | VAR 658426 | | Number of Individuals Covered | 71 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $352 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | VOLUNTARY AD&D | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $2,345 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | SOK601769 |
| Policy instance | 5 |
| Insurance contract or identification number | SOK601769 | | Number of Individuals Covered | 223 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $253 | | Total amount of fees paid to insurance company | USD $50 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $2,376 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | SGM602836 |
| Policy instance | 4 |
| Insurance contract or identification number | SGM602836 | | Number of Individuals Covered | 223 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $2,839 | | Total amount of fees paid to insurance company | USD $425 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $28,409 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| DELTA DENTAL OF IOWA (National Association of Insurance Commissioners NAIC id number: 55786 ) |
| Policy contract number | 902 |
| Policy instance | 3 |
| Insurance contract or identification number | 902 | | Number of Individuals Covered | 158 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $5,818 | | Total amount of fees paid to insurance company | USD $1,151 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $96,973 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| WELLMARK HEALTH PLAN OF IOWA (National Association of Insurance Commissioners NAIC id number: 95531 ) |
| Policy contract number | 00016367 |
| Policy instance | 2 |
| Insurance contract or identification number | 00016367 | | Number of Individuals Covered | 152 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $35,934 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,206,532 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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| WELLMARK BLUE CROSS BLUE SHIELD OF SOUTH DAKOTA (National Association of Insurance Commissioners NAIC id number: 88848 ) |
| Policy contract number | 00016367 |
| Policy instance | 1 |
| Insurance contract or identification number | 00016367 | | Number of Individuals Covered | 3 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $734 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $24,938 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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| AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 ) |
| Policy contract number | 010-034846 |
| Policy instance | 6 |
| Insurance contract or identification number | 010-034846 | | Number of Individuals Covered | 178 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $678 | | Total amount of fees paid to insurance company | USD $49 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $6,783 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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