PROVIDENCE MEDICAL GROUP, INC. has sponsored the creation of one or more 401k plans.
Additional information about PROVIDENCE MEDICAL GROUP, INC.
Submission information for form 5500 for 401k plan PROVIDENCE MEDICAL GROUP INC WELFARE BENEFIT PLAN
401k plan membership statisitcs for PROVIDENCE MEDICAL GROUP INC WELFARE BENEFIT PLAN
| Measure | Date | Value |
|---|
| 2022: PROVIDENCE MEDICAL GROUP INC WELFARE BENEFIT PLAN 2022 401k membership |
|---|
| Total participants, beginning-of-year | 2022-01-01 | 229 |
| Total number of active participants reported on line 7a of the Form 5500 | 2022-01-01 | 268 |
| Total of all active and inactive participants | 2022-01-01 | 268 |
| 2021: PROVIDENCE MEDICAL GROUP INC WELFARE BENEFIT PLAN 2021 401k membership |
|---|
| Total participants, beginning-of-year | 2021-01-01 | 231 |
| Total number of active participants reported on line 7a of the Form 5500 | 2021-01-01 | 229 |
| Total of all active and inactive participants | 2021-01-01 | 229 |
| 2020: PROVIDENCE MEDICAL GROUP INC WELFARE BENEFIT PLAN 2020 401k membership |
|---|
| Total participants, beginning-of-year | 2020-01-01 | 212 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-01-01 | 231 |
| Total of all active and inactive participants | 2020-01-01 | 231 |
| 2019: PROVIDENCE MEDICAL GROUP INC WELFARE BENEFIT PLAN 2019 401k membership |
|---|
| Total participants, beginning-of-year | 2019-01-01 | 175 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-01-01 | 212 |
| Total of all active and inactive participants | 2019-01-01 | 212 |
| 2018: PROVIDENCE MEDICAL GROUP INC WELFARE BENEFIT PLAN 2018 401k membership |
|---|
| Total participants, beginning-of-year | 2018-01-01 | 197 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-01-01 | 175 |
| Total of all active and inactive participants | 2018-01-01 | 175 |
| 2017: PROVIDENCE MEDICAL GROUP INC WELFARE BENEFIT PLAN 2017 401k membership |
|---|
| Total participants, beginning-of-year | 2017-01-01 | 254 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-01-01 | 197 |
| Total of all active and inactive participants | 2017-01-01 | 197 |
| 2016: PROVIDENCE MEDICAL GROUP INC WELFARE BENEFIT PLAN 2016 401k membership |
|---|
| Total participants, beginning-of-year | 2016-01-01 | 272 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-01-01 | 254 |
| Total of all active and inactive participants | 2016-01-01 | 254 |
| 2015: PROVIDENCE MEDICAL GROUP INC WELFARE BENEFIT PLAN 2015 401k membership |
|---|
| Total participants, beginning-of-year | 2015-01-01 | 256 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-01-01 | 272 |
| Total of all active and inactive participants | 2015-01-01 | 272 |
| 2014: PROVIDENCE MEDICAL GROUP INC WELFARE BENEFIT PLAN 2014 401k membership |
|---|
| Total participants, beginning-of-year | 2014-01-01 | 256 |
| Total number of active participants reported on line 7a of the Form 5500 | 2014-01-01 | 256 |
| Total of all active and inactive participants | 2014-01-01 | 256 |
| 2013: PROVIDENCE MEDICAL GROUP INC WELFARE BENEFIT PLAN 2013 401k membership |
|---|
| Total participants, beginning-of-year | 2013-01-01 | 254 |
| Total number of active participants reported on line 7a of the Form 5500 | 2013-01-01 | 256 |
| Total of all active and inactive participants | 2013-01-01 | 256 |
| 2012: PROVIDENCE MEDICAL GROUP INC WELFARE BENEFIT PLAN 2012 401k membership |
|---|
| Total participants, beginning-of-year | 2012-01-01 | 244 |
| Total number of active participants reported on line 7a of the Form 5500 | 2012-01-01 | 254 |
| Total of all active and inactive participants | 2012-01-01 | 254 |
| 2011: PROVIDENCE MEDICAL GROUP INC WELFARE BENEFIT PLAN 2011 401k membership |
|---|
| Total participants, beginning-of-year | 2011-01-01 | 239 |
| Total number of active participants reported on line 7a of the Form 5500 | 2011-01-01 | 244 |
| Total of all active and inactive participants | 2011-01-01 | 244 |
| 2009: PROVIDENCE MEDICAL GROUP INC WELFARE BENEFIT PLAN 2009 401k membership |
|---|
| Total participants, beginning-of-year | 2009-01-01 | 246 |
| Total number of active participants reported on line 7a of the Form 5500 | 2009-01-01 | 258 |
| Total of all active and inactive participants | 2009-01-01 | 258 |
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 923756 |
| Policy instance | 4 |
| Insurance contract or identification number | 923756 | | Number of Individuals Covered | 108 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $11,236 | | Total amount of fees paid to insurance company | USD $0 | | Welfare Benefit Premiums Paid to Carrier | USD $245,664 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,376 | | Insurance broker organization code? | 3 |
|
| DENTAL CARE PLUS, INC. (National Association of Insurance Commissioners NAIC id number: 96265 ) |
| Policy contract number | 081270 |
| Policy instance | 3 |
| Insurance contract or identification number | 081270 | | Number of Individuals Covered | 214 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $3,343 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $71,196 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,343 | | Insurance broker organization code? | 3 |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 98020421001 |
| Policy instance | 2 |
| Insurance contract or identification number | 98020421001 | | Number of Individuals Covered | 179 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $1,268 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $12,589 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,268 | | Insurance broker organization code? | 3 |
|
| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
| Policy contract number | 676667G |
| Policy instance | 1 |
| Insurance contract or identification number | 676667G | | Number of Individuals Covered | 268 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $16,252 | | Total amount of fees paid to insurance company | USD $10,792 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $129,772 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $16,252 | | Amount paid for insurance broker fees | 8845 | | Additional information about fees paid to insurance broker | BONUS PAID | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 607604 |
| Policy instance | 1 |
| Insurance contract or identification number | 607604 | | Number of Individuals Covered | 229 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2022-01-01 | | Total amount of commissions paid to insurance broker | USD $9,088 | | Total amount of fees paid to insurance company | USD $1,528 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $98,317 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $9,088 | | Amount paid for insurance broker fees | 1528 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 607605 |
| Policy instance | 2 |
| Insurance contract or identification number | 607605 | | Number of Individuals Covered | 125 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2022-01-01 | | Total amount of commissions paid to insurance broker | USD $10,651 | | Total amount of fees paid to insurance company | USD $1,420 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $71,008 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $10,651 | | Amount paid for insurance broker fees | 1420 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | | Insurance broker organization code? | 3 |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 98020421001 |
| Policy instance | 3 |
| Insurance contract or identification number | 98020421001 | | Number of Individuals Covered | 221 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $1,369 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $12,207 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,369 | | Insurance broker organization code? | 3 |
|
| DENTAL CARE PLUS, INC. (National Association of Insurance Commissioners NAIC id number: 96265 ) |
| Policy contract number | 081270 |
| Policy instance | 4 |
| Insurance contract or identification number | 081270 | | Number of Individuals Covered | 237 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2022-01-01 | | Total amount of commissions paid to insurance broker | USD $3,433 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $80,355 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,433 | | Insurance broker organization code? | 3 |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 923756 |
| Policy instance | 5 |
| Insurance contract or identification number | 923756 | | Number of Individuals Covered | 123 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $13,163 | | Total amount of fees paid to insurance company | USD $0 | | Welfare Benefit Premiums Paid to Carrier | USD $284,909 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,547 | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 607604 |
| Policy instance | 1 |
| Insurance contract or identification number | 607604 | | Number of Individuals Covered | 231 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2021-01-01 | | Total amount of commissions paid to insurance broker | USD $7,949 | | Total amount of fees paid to insurance company | USD $1,675 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $90,642 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,949 | | Amount paid for insurance broker fees | 1675 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 607605 |
| Policy instance | 2 |
| Insurance contract or identification number | 607605 | | Number of Individuals Covered | 135 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2021-01-01 | | Total amount of commissions paid to insurance broker | USD $12,247 | | Total amount of fees paid to insurance company | USD $1,633 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $81,648 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $12,247 | | Amount paid for insurance broker fees | 1633 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | | Insurance broker organization code? | 3 |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 98020421001 |
| Policy instance | 3 |
| Insurance contract or identification number | 98020421001 | | Number of Individuals Covered | 245 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $1,263 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $14,494 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,263 | | Insurance broker organization code? | 3 |
|
| DENTAL CARE PLUS, INC. (National Association of Insurance Commissioners NAIC id number: 96265 ) |
| Policy contract number | 8128801 |
| Policy instance | 4 |
| Insurance contract or identification number | 8128801 | | Number of Individuals Covered | 233 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $5,275 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $75,851 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,275 | | Insurance broker organization code? | 3 |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 923756 |
| Policy instance | 5 |
| Insurance contract or identification number | 923756 | | Number of Individuals Covered | 120 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $13,197 | | Total amount of fees paid to insurance company | USD $0 | | Welfare Benefit Premiums Paid to Carrier | USD $284,608 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,538 | | Insurance broker organization code? | 3 |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 923756 |
| Policy instance | 5 |
| Insurance contract or identification number | 923756 | | Number of Individuals Covered | 118 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $11,063 | | Total amount of fees paid to insurance company | USD $0 | | Welfare Benefit Premiums Paid to Carrier | USD $236,644 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,099 | | Insurance broker organization code? | 3 |
|
| DENTAL CARE PLUS, INC. (National Association of Insurance Commissioners NAIC id number: 96265 ) |
| Policy contract number | 8128801 |
| Policy instance | 4 |
| Insurance contract or identification number | 8128801 | | Number of Individuals Covered | 230 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $5,034 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $76,365 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,034 | | Insurance broker organization code? | 3 |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 98020421001 |
| Policy instance | 3 |
| Insurance contract or identification number | 98020421001 | | Number of Individuals Covered | 220 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $1,020 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $11,509 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,020 | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 607605 |
| Policy instance | 2 |
| Insurance contract or identification number | 607605 | | Number of Individuals Covered | 119 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2020-01-01 | | Total amount of commissions paid to insurance broker | USD $10,670 | | Total amount of fees paid to insurance company | USD $1,423 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $71,132 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $10,670 | | Amount paid for insurance broker fees | 1423 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 607604 |
| Policy instance | 1 |
| Insurance contract or identification number | 607604 | | Number of Individuals Covered | 212 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2020-01-01 | | Total amount of commissions paid to insurance broker | USD $7,295 | | Total amount of fees paid to insurance company | USD $1,434 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $84,646 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,295 | | Amount paid for insurance broker fees | 1434 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | | Insurance broker organization code? | 3 |
|
| CONTINENTAL AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71730 ) |
| Policy contract number | 21686 |
| Policy instance | 7 |
| Insurance contract or identification number | 21686 | | Number of Individuals Covered | 115 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $3,946 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $16,879 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,838 | | Insurance broker organization code? | 3 |
|
| AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 ) |
| Policy contract number | HP672 |
| Policy instance | 6 |
| Insurance contract or identification number | HP672 | | Number of Individuals Covered | 1 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $174 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $2,116 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $69 | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 607604 |
| Policy instance | 1 |
| Insurance contract or identification number | 607604 | | Number of Individuals Covered | 175 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2019-01-01 | | Total amount of commissions paid to insurance broker | USD $8,665 | | Total amount of fees paid to insurance company | USD $4,300 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $85,997 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,665 | | Amount paid for insurance broker fees | 4300 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 607605 |
| Policy instance | 2 |
| Insurance contract or identification number | 607605 | | Number of Individuals Covered | 109 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2019-01-01 | | Total amount of commissions paid to insurance broker | USD $10,472 | | Total amount of fees paid to insurance company | USD $3,424 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $68,479 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $10,472 | | Amount paid for insurance broker fees | 3424 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | | Insurance broker organization code? | 3 |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 98020421001 |
| Policy instance | 3 |
| Insurance contract or identification number | 98020421001 | | Number of Individuals Covered | 227 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $1,016 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $15,462 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,016 | | Insurance broker organization code? | 3 |
|
| DENTAL CARE PLUS, INC. (National Association of Insurance Commissioners NAIC id number: 96265 ) |
| Policy contract number | 8128801 |
| Policy instance | 4 |
| Insurance contract or identification number | 8128801 | | Number of Individuals Covered | 252 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $7,939 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $101,895 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,939 | | Insurance broker organization code? | 3 |
|
| COMMUNITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 10345 ) |
| Policy contract number | 00171920 |
| Policy instance | 5 |
| Insurance contract or identification number | 00171920 | | Number of Individuals Covered | 247 | | 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 $1,932 | | Welfare Benefit Premiums Paid to Carrier | USD $210,474 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 1932 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AK3Q |
| Policy instance | 2 |
| Insurance contract or identification number | G000AK3Q | | Number of Individuals Covered | 192 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2018-01-01 | | Total amount of commissions paid to insurance broker | USD $3,869 | | Total amount of fees paid to insurance company | USD $0 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $47,389 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,869 | | Insurance broker organization code? | 3 | | Insurance broker name | MCGOHAN/BRABENDER AGENCY INC |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 98020421001 |
| Policy instance | 3 |
| Insurance contract or identification number | 98020421001 | | Number of Individuals Covered | 303 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $1,907 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $18,801 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,880 | | Insurance broker organization code? | 3 | | Insurance broker name | MARSH & MCLENNAN AGENCY LLC |
|
| DENTAL CARE PLUS, INC. (National Association of Insurance Commissioners NAIC id number: 96265 ) |
| Policy contract number | 8128801 |
| Policy instance | 4 |
| Insurance contract or identification number | 8128801 | | Number of Individuals Covered | 331 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $8,112 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $103,481 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,112 | | Insurance broker organization code? | 3 | | Insurance broker name | MCGOHAN/BRABENDER AGENCY INC |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AK3Q |
| Policy instance | 5 |
| Insurance contract or identification number | G000AK3Q | | Number of Individuals Covered | 109 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2018-01-01 | | Total amount of commissions paid to insurance broker | USD $4,500 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $69,993 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,500 | | Insurance broker organization code? | 3 | | Insurance broker name | MCGOHAN/BRABENDER AGENCY INC |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AK3Q |
| Policy instance | 6 |
| Insurance contract or identification number | G000AK3Q | | Number of Individuals Covered | 192 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2018-01-01 | | Total amount of commissions paid to insurance broker | USD $3,950 | | Total amount of fees paid to insurance company | USD $0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $48,997 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,950 | | Insurance broker organization code? | 3 | | Insurance broker name | MCGOHAN/BRABENDER AGENCY INC |
|
| COMMUNITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 10345 ) |
| Policy contract number | 00171920 |
| Policy instance | 7 |
| Insurance contract or identification number | 00171920 | | Number of Individuals Covered | 301 | | 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 $1,765 | | Welfare Benefit Premiums Paid to Carrier | USD $209,610 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 1765 | | Insurance broker organization code? | 3 | | Insurance broker name | MCGOHAN/BRABENDER AGENCY INC |
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| AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 ) |
| Policy contract number | HP672 |
| Policy instance | 8 |
| Insurance contract or identification number | HP672 | | Number of Individuals Covered | 1 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $230 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $2,669 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $77 | | Insurance broker organization code? | 3 | | Insurance broker name | JOHN C RASCHELLA |
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| CONTINENTAL AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71730 ) |
| Policy contract number | 21686 |
| Policy instance | 9 |
| Insurance contract or identification number | 21686 | | Number of Individuals Covered | 93 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $5,440 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $24,170 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,479 | | Insurance broker organization code? | 3 | | Insurance broker name | MARSH & MCLENNAN AGENCY LLC |
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| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AK3Q |
| Policy instance | 1 |
| Insurance contract or identification number | G000AK3Q | | Number of Individuals Covered | 197 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2018-01-01 | | Total amount of commissions paid to insurance broker | USD $2,312 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $23,122 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,312 | | Insurance broker organization code? | 3 | | Insurance broker name | MCGOHAN/BRABENDER AGENCY INC |
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