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KANSAS CITY INTERNAL MEDICINE, PA MEDICAL, DENTAL, LONG TERM DISABILITY, LIFE AND ACCIDENTAL DEATH AND DISMEMBERMENT PLAN 401k Plan overview

Plan NameKANSAS CITY INTERNAL MEDICINE, PA MEDICAL, DENTAL, LONG TERM DISABILITY, LIFE AND ACCIDENTAL DEATH AND DISMEMBERMENT PLAN
Plan identification number 505

KANSAS CITY INTERNAL MEDICINE, PA MEDICAL, DENTAL, LONG TERM DISABILITY, LIFE AND ACCIDENTAL DEATH AND DISMEMBERMENT PLAN Benefits

401k Plan TypeWelfare Benefit
Plan Features/Benefits
  • Health (other than dental or vision)
  • Life insurance
  • Dental
  • Long-term disability cover
  • Death benefits (include travel accident but not life insurance)

401k Sponsoring company profile

KANSAS CITY INTERNAL MEDICINE PA has sponsored the creation of one or more 401k plans.

Company Name:KANSAS CITY INTERNAL MEDICINE PA
Employer identification number (EIN):431201337
NAIC Classification:621111
NAIC Description:Offices of Physicians (except Mental Health Specialists)

Form 5500 Filing Information

Submission information for form 5500 for 401k plan KANSAS CITY INTERNAL MEDICINE, PA MEDICAL, DENTAL, LONG TERM DISABILITY, LIFE AND ACCIDENTAL DEATH AND DISMEMBERMENT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5052015-01-01JEAN A. HANSEN
5052014-01-01JEAN A. HANSEN
5052013-01-01JEAN A. HANSEN
5052012-01-01JEAN A. HANSEN
5052011-01-01LORI A. MALLORY
5052010-01-01LORI A MALLORY
5052009-01-01LORI A. MALLORY LORI A. MALLORY2010-07-21

Plan Statistics for KANSAS CITY INTERNAL MEDICINE, PA MEDICAL, DENTAL, LONG TERM DISABILITY, LIFE AND ACCIDENTAL DEATH AND DISMEMBERMENT PLAN

401k plan membership statisitcs for KANSAS CITY INTERNAL MEDICINE, PA MEDICAL, DENTAL, LONG TERM DISABILITY, LIFE AND ACCIDENTAL DEATH AND DISMEMBERMENT PLAN

Measure Date Value
2015: KANSAS CITY INTERNAL MEDICINE, PA MEDICAL, DENTAL, LONG TERM DISABILITY, LIFE AND ACCIDENTAL DEATH AND DISMEMBERMENT PLAN 2015 401k membership
Total participants, beginning-of-year2015-01-01213
Total number of active participants reported on line 7a of the Form 55002015-01-010
Number of retired or separated participants receiving benefits2015-01-010
Number of other retired or separated participants entitled to future benefits2015-01-010
Total of all active and inactive participants2015-01-010
2014: KANSAS CITY INTERNAL MEDICINE, PA MEDICAL, DENTAL, LONG TERM DISABILITY, LIFE AND ACCIDENTAL DEATH AND DISMEMBERMENT PLAN 2014 401k membership
Total participants, beginning-of-year2014-01-01225
Total number of active participants reported on line 7a of the Form 55002014-01-01206
Number of retired or separated participants receiving benefits2014-01-017
Number of other retired or separated participants entitled to future benefits2014-01-010
Total of all active and inactive participants2014-01-01213
2013: KANSAS CITY INTERNAL MEDICINE, PA MEDICAL, DENTAL, LONG TERM DISABILITY, LIFE AND ACCIDENTAL DEATH AND DISMEMBERMENT PLAN 2013 401k membership
Total participants, beginning-of-year2013-01-01159
Total number of active participants reported on line 7a of the Form 55002013-01-01181
Number of retired or separated participants receiving benefits2013-01-013
Number of other retired or separated participants entitled to future benefits2013-01-010
Total of all active and inactive participants2013-01-01184
2012: KANSAS CITY INTERNAL MEDICINE, PA MEDICAL, DENTAL, LONG TERM DISABILITY, LIFE AND ACCIDENTAL DEATH AND DISMEMBERMENT PLAN 2012 401k membership
Total participants, beginning-of-year2012-01-01157
Total number of active participants reported on line 7a of the Form 55002012-01-01159
Number of retired or separated participants receiving benefits2012-01-013
Number of other retired or separated participants entitled to future benefits2012-01-010
Total of all active and inactive participants2012-01-01162
2011: KANSAS CITY INTERNAL MEDICINE, PA MEDICAL, DENTAL, LONG TERM DISABILITY, LIFE AND ACCIDENTAL DEATH AND DISMEMBERMENT PLAN 2011 401k membership
Total participants, beginning-of-year2011-01-01157
Total number of active participants reported on line 7a of the Form 55002011-01-01157
Number of retired or separated participants receiving benefits2011-01-011
Number of other retired or separated participants entitled to future benefits2011-01-010
Total of all active and inactive participants2011-01-01158
2010: KANSAS CITY INTERNAL MEDICINE, PA MEDICAL, DENTAL, LONG TERM DISABILITY, LIFE AND ACCIDENTAL DEATH AND DISMEMBERMENT PLAN 2010 401k membership
Total participants, beginning-of-year2010-01-01102
Total number of active participants reported on line 7a of the Form 55002010-01-01108
Number of retired or separated participants receiving benefits2010-01-011
Number of other retired or separated participants entitled to future benefits2010-01-010
Total of all active and inactive participants2010-01-01109
2009: KANSAS CITY INTERNAL MEDICINE, PA MEDICAL, DENTAL, LONG TERM DISABILITY, LIFE AND ACCIDENTAL DEATH AND DISMEMBERMENT PLAN 2009 401k membership
Total participants, beginning-of-year2009-01-01132
Total number of active participants reported on line 7a of the Form 55002009-01-01140
Number of retired or separated participants receiving benefits2009-01-010
Number of other retired or separated participants entitled to future benefits2009-01-010
Total of all active and inactive participants2009-01-01140

Form 5500 Responses for KANSAS CITY INTERNAL MEDICINE, PA MEDICAL, DENTAL, LONG TERM DISABILITY, LIFE AND ACCIDENTAL DEATH AND DISMEMBERMENT PLAN

2015: KANSAS CITY INTERNAL MEDICINE, PA MEDICAL, DENTAL, LONG TERM DISABILITY, LIFE AND ACCIDENTAL DEATH AND DISMEMBERMENT PLAN 2015 form 5500 responses
2015-01-01Type of plan entitySingle employer plan
2015-01-01Submission has been amendedNo
2015-01-01This submission is the final filingYes
2015-01-01This return/report is a short plan year return/report (less than 12 months)No
2015-01-01Plan is a collectively bargained planNo
2015-01-01Plan funding arrangement – InsuranceYes
2015-01-01Plan benefit arrangement – InsuranceYes
2014: KANSAS CITY INTERNAL MEDICINE, PA MEDICAL, DENTAL, LONG TERM DISABILITY, LIFE AND ACCIDENTAL DEATH AND DISMEMBERMENT PLAN 2014 form 5500 responses
2014-01-01Type of plan entitySingle employer plan
2014-01-01Submission has been amendedNo
2014-01-01This submission is the final filingNo
2014-01-01This return/report is a short plan year return/report (less than 12 months)No
2014-01-01Plan is a collectively bargained planNo
2014-01-01Plan funding arrangement – InsuranceYes
2014-01-01Plan benefit arrangement – InsuranceYes
2013: KANSAS CITY INTERNAL MEDICINE, PA MEDICAL, DENTAL, LONG TERM DISABILITY, LIFE AND ACCIDENTAL DEATH AND DISMEMBERMENT PLAN 2013 form 5500 responses
2013-01-01Type of plan entitySingle employer plan
2013-01-01Submission has been amendedNo
2013-01-01This submission is the final filingNo
2013-01-01This return/report is a short plan year return/report (less than 12 months)No
2013-01-01Plan is a collectively bargained planNo
2013-01-01Plan funding arrangement – InsuranceYes
2013-01-01Plan benefit arrangement – InsuranceYes
2012: KANSAS CITY INTERNAL MEDICINE, PA MEDICAL, DENTAL, LONG TERM DISABILITY, LIFE AND ACCIDENTAL DEATH AND DISMEMBERMENT PLAN 2012 form 5500 responses
2012-01-01Type of plan entitySingle employer plan
2012-01-01Submission has been amendedNo
2012-01-01This submission is the final filingNo
2012-01-01This return/report is a short plan year return/report (less than 12 months)No
2012-01-01Plan is a collectively bargained planNo
2012-01-01Plan funding arrangement – InsuranceYes
2012-01-01Plan benefit arrangement – InsuranceYes
2011: KANSAS CITY INTERNAL MEDICINE, PA MEDICAL, DENTAL, LONG TERM DISABILITY, LIFE AND ACCIDENTAL DEATH AND DISMEMBERMENT PLAN 2011 form 5500 responses
2011-01-01Type of plan entitySingle employer plan
2011-01-01Submission has been amendedNo
2011-01-01This submission is the final filingNo
2011-01-01This return/report is a short plan year return/report (less than 12 months)No
2011-01-01Plan is a collectively bargained planNo
2011-01-01Plan funding arrangement – InsuranceYes
2011-01-01Plan benefit arrangement – InsuranceYes
2010: KANSAS CITY INTERNAL MEDICINE, PA MEDICAL, DENTAL, LONG TERM DISABILITY, LIFE AND ACCIDENTAL DEATH AND DISMEMBERMENT PLAN 2010 form 5500 responses
2010-01-01Type of plan entitySingle employer plan
2010-01-01Submission has been amendedNo
2010-01-01This submission is the final filingNo
2010-01-01This return/report is a short plan year return/report (less than 12 months)No
2010-01-01Plan is a collectively bargained planNo
2010-01-01Plan funding arrangement – InsuranceYes
2010-01-01Plan benefit arrangement – InsuranceYes
2009: KANSAS CITY INTERNAL MEDICINE, PA MEDICAL, DENTAL, LONG TERM DISABILITY, LIFE AND ACCIDENTAL DEATH AND DISMEMBERMENT PLAN 2009 form 5500 responses
2009-01-01Type of plan entitySingle employer plan
2009-01-01Submission has been amendedNo
2009-01-01This submission is the final filingNo
2009-01-01This return/report is a short plan year return/report (less than 12 months)No
2009-01-01Plan is a collectively bargained planNo
2009-01-01Plan funding arrangement – InsuranceYes
2009-01-01Plan benefit arrangement – InsuranceYes

Insurance Providers Used on plan

BLUE CROSS AND BLUE SHIELD OF KANSAS CITY (National Association of Insurance Commissioners NAIC id number: 47171 )
Policy contract number31826000
Policy instance 1
Insurance contract or identification number31826000
Number of Individuals Covered148
Insurance policy start date2015-01-01
Insurance policy end date2015-12-31
Total amount of commissions paid to insurance brokerUSD $14,938
Total amount of fees paid to insurance companyUSD $19,400
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $14,938
Amount paid for insurance broker fees19400
Additional information about fees paid to insurance brokerPROVISION OF ADMINISTRATIVE SERVICES TO BCBSKC
Insurance broker organization code?3
Insurance broker nameCBIZ BENEFITS & INSURANCE SERVICES
DELTA DENTAL OF KANSAS (National Association of Insurance Commissioners NAIC id number: 54615 )
Policy contract number50608-000-00001
Policy instance 4
Insurance contract or identification number50608-000-00001
Number of Individuals Covered105
Insurance policy start date2015-01-01
Insurance policy end date2015-12-31
Total amount of commissions paid to insurance brokerUSD $4,032
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $68,663
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,032
Insurance broker organization code?3
Insurance broker nameCBIZ BENEFITS & INSURANCE SERVICES
STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )
Policy contract number155456
Policy instance 3
Insurance contract or identification number155456
Number of Individuals Covered157
Insurance policy start date2015-01-01
Insurance policy end date2015-12-31
Total amount of commissions paid to insurance brokerUSD $3,783
Total amount of fees paid to insurance companyUSD $624
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,480
Insurance broker organization code?3
Amount paid for insurance broker fees624
Additional information about fees paid to insurance brokerCONTINGENT COMPENSATION
Insurance broker nameCBIZ BENEFITS & INSURANCE SERVICES
STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )
Policy contract number155456
Policy instance 2
Insurance contract or identification number155456
Number of Individuals Covered228
Insurance policy start date2015-01-01
Insurance policy end date2015-12-31
Total amount of commissions paid to insurance brokerUSD $2,327
Total amount of fees paid to insurance companyUSD $584
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH & DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,176
Insurance broker organization code?3
Amount paid for insurance broker fees584
Additional information about fees paid to insurance brokerCONTINGENT COMPENSATION
Insurance broker nameCBIZ BENEFITS & INSURANCE SERVICES
STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )
Policy contract number155456
Policy instance 3
Insurance contract or identification number155456
Number of Individuals Covered182
Insurance policy start date2014-01-01
Insurance policy end date2014-12-31
Total amount of commissions paid to insurance brokerUSD $3,422
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,422
Insurance broker organization code?3
Insurance broker nameCBIZ BENEFITS & INSURANCE SERVICES
STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )
Policy contract number155456
Policy instance 2
Insurance contract or identification number155456
Number of Individuals Covered250
Insurance policy start date2014-01-01
Insurance policy end date2014-12-31
Total amount of commissions paid to insurance brokerUSD $2,131
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH & DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,131
Insurance broker organization code?3
Insurance broker nameCBIZ BENEFITS & INSURANCE SERVICES
BLUE CROSS AND BLUE SHIELD OF KANSAS CITY (National Association of Insurance Commissioners NAIC id number: 47171 )
Policy contract number31826000
Policy instance 1
Insurance contract or identification number31826000
Number of Individuals Covered213
Insurance policy start date2014-01-01
Insurance policy end date2014-12-31
Total amount of commissions paid to insurance brokerUSD $15,145
Total amount of fees paid to insurance companyUSD $19,783
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $15,145
Amount paid for insurance broker fees19783
Additional information about fees paid to insurance broker$19,541PROVISION OF ADMINISTRATIVE SERVICES TO BCBSKC AND $242 IN OTHER NON-MONETARY COMPENSATION
Insurance broker organization code?3
Insurance broker nameCBIZ BENEFITS & INSURANCE SERVICES
DELTA DENTAL OF KANSAS (National Association of Insurance Commissioners NAIC id number: 54615 )
Policy contract number50608-000-00001
Policy instance 4
Insurance contract or identification number50608-000-00001
Number of Individuals Covered122
Insurance policy start date2014-01-01
Insurance policy end date2014-12-31
Total amount of commissions paid to insurance brokerUSD $4,568
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $80,250
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,568
Insurance broker organization code?3
Insurance broker nameCBIZ BENEFITS & INSURANCE SERVICES
STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )
Policy contract number155456
Policy instance 3
Insurance contract or identification number155456
Number of Individuals Covered181
Insurance policy start date2013-01-01
Insurance policy end date2013-12-31
Total amount of commissions paid to insurance brokerUSD $3,606
Total amount of fees paid to insurance companyUSD $769
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,606
Amount paid for insurance broker fees769
Additional information about fees paid to insurance brokerCONTINGENT COMPENSATION
Insurance broker organization code?3
Insurance broker nameCBIZ BENEFITS & INSURANCE SERVICES
DELTA DENTAL OF KANSAS (National Association of Insurance Commissioners NAIC id number: 54615 )
Policy contract number50608
Policy instance 4
Insurance contract or identification number50608
Number of Individuals Covered124
Insurance policy start date2013-01-01
Insurance policy end date2013-12-31
Total amount of commissions paid to insurance brokerUSD $3,655
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $73,099
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,655
Insurance broker organization code?3
Insurance broker nameCBIZ BENEFITS & INSURANCE SERVICES
BLUE CROSS AND BLUE SHIELD OF KANSAS CITY (National Association of Insurance Commissioners NAIC id number: 47171 )
Policy contract number31826000
Policy instance 1
Insurance contract or identification number31826000
Number of Individuals Covered350
Insurance policy start date2013-01-01
Insurance policy end date2013-12-31
Total amount of commissions paid to insurance brokerUSD $14,494
Total amount of fees paid to insurance companyUSD $17,863
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $14,494
Amount paid for insurance broker fees17863
Additional information about fees paid to insurance brokerPROVISION OF ADMINISTRATIVE SERVICES TO BCBSKC
Insurance broker organization code?3
Insurance broker nameCBIZ BENEFITS & INSURANCE SERVICES
STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )
Policy contract number155456
Policy instance 2
Insurance contract or identification number155456
Number of Individuals Covered257
Insurance policy start date2013-01-01
Insurance policy end date2013-12-31
Total amount of commissions paid to insurance brokerUSD $2,364
Total amount of fees paid to insurance companyUSD $887
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH & DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,364
Amount paid for insurance broker fees887
Additional information about fees paid to insurance brokerCONTINGENT COMPENSATION
Insurance broker organization code?3
Insurance broker nameCBIZ BENEFITS & INSURANCE SERVICES
BLUE CROSS AND BLUE SHIELD OF KANSAS CITY (National Association of Insurance Commissioners NAIC id number: 47171 )
Policy contract number31826000
Policy instance 1
Insurance contract or identification number31826000
Number of Individuals Covered192
Insurance policy start date2012-01-01
Insurance policy end date2012-12-31
Total amount of commissions paid to insurance brokerUSD $13,438
Total amount of fees paid to insurance companyUSD $15,893
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?Yes
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $13,438
Amount paid for insurance broker fees15893
Additional information about fees paid to insurance brokerPROVISION OF ADMINISTRATIVE SERVICES TO BCBSKC OF $15,746 AND NON-MONETARY COMPENSATION OF $147
Insurance broker organization code?3
Insurance broker nameCBIZ BENEFITS & INSURANCE SERVICES
USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )
Policy contract number50001827
Policy instance 5
Insurance contract or identification number50001827
Number of Individuals Covered52
Insurance policy start date2012-01-01
Insurance policy end date2012-12-31
Total amount of commissions paid to insurance brokerUSD $381
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH & 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 CarrierUSD $1,780
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $198
Insurance broker organization code?3
Insurance broker nameBLUE CROSS BLUE SHIELD OF KC
USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )
Policy contract number50001827
Policy instance 4
Insurance contract or identification number50001827
Number of Individuals Covered126
Insurance policy start date2012-01-01
Insurance policy end date2012-12-31
Total amount of commissions paid to insurance brokerUSD $5,384
Total amount of fees paid to insurance companyUSD $673
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $33,653
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,365
Insurance broker organization code?3
Amount paid for insurance broker fees673
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
Insurance broker nameBLUE CROSS BLUE SHIELD OF KC
USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )
Policy contract number50001827
Policy instance 3
Insurance contract or identification number50001827
Number of Individuals Covered107
Insurance policy start date2012-01-01
Insurance policy end date2012-12-31
Total amount of commissions paid to insurance brokerUSD $4,431
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $20,350
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,304
Insurance broker organization code?3
Insurance broker nameCBIZ BENEFITS & INSURANCE SERVICES
USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )
Policy contract number50001827
Policy instance 2
Insurance contract or identification number50001827
Number of Individuals Covered126
Insurance policy start date2012-01-01
Insurance policy end date2012-12-31
Total amount of commissions paid to insurance brokerUSD $1,691
Total amount of fees paid to insurance companyUSD $212
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH & 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 CarrierUSD $10,574
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,057
Insurance broker organization code?3
Amount paid for insurance broker fees212
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
Insurance broker nameBLUE CROSS BLUE SHIELD OF KC
USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )
Policy contract number50001827
Policy instance 4
Insurance contract or identification number50001827
Number of Individuals Covered150
Insurance policy start date2011-01-01
Insurance policy end date2011-12-31
Total amount of commissions paid to insurance brokerUSD $3,850
Total amount of fees paid to insurance companyUSD $481
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $24,058
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )
Policy contract number50001827
Policy instance 3
Insurance contract or identification number50001827
Number of Individuals Covered103
Insurance policy start date2011-01-01
Insurance policy end date2011-12-31
Total amount of commissions paid to insurance brokerUSD $4,155
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $16,618
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )
Policy contract number50001827
Policy instance 2
Insurance contract or identification number50001827
Number of Individuals Covered142
Insurance policy start date2011-01-01
Insurance policy end date2011-12-31
Total amount of commissions paid to insurance brokerUSD $1,491
Total amount of fees paid to insurance companyUSD $186
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH & 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 CarrierUSD $9,320
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
BLUE CROSS AND BLUE SHIELD OF KANSAS CITY (National Association of Insurance Commissioners NAIC id number: 47171 )
Policy contract number31826000
Policy instance 1
Insurance contract or identification number31826000
Number of Individuals Covered184
Insurance policy start date2011-01-01
Insurance policy end date2011-12-31
Total amount of commissions paid to insurance brokerUSD $13,158
Total amount of fees paid to insurance companyUSD $14,852
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )
Policy contract number50001827
Policy instance 5
Insurance contract or identification number50001827
Number of Individuals Covered53
Insurance policy start date2011-01-01
Insurance policy end date2011-12-31
Total amount of commissions paid to insurance brokerUSD $399
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH & 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 CarrierUSD $1,594
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )
Policy contract number1602
Policy instance 5
Insurance contract or identification number1602
Number of Individuals Covered48
Insurance policy start date2010-01-01
Insurance policy end date2010-12-31
Total amount of commissions paid to insurance brokerUSD $3,262
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $13,047
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,795
Insurance broker organization code?3
Insurance broker nameCBIZ BENEFITS & INSURANCE SERVICES
USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )
Policy contract number1826
Policy instance 3
Insurance contract or identification number1826
Number of Individuals Covered140
Insurance policy start date2010-01-01
Insurance policy end date2010-11-30
Total amount of commissions paid to insurance brokerUSD $2,270
Total amount of fees paid to insurance companyUSD $175
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH & 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 CarrierUSD $8,728
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,397
Insurance broker organization code?3
Amount paid for insurance broker fees175
Additional information about fees paid to insurance brokerFEES PAID
Insurance broker nameWILLIS OF GREATER KANSAS INC.
USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )
Policy contract number1826
Policy instance 2
Insurance contract or identification number1826
Number of Individuals Covered140
Insurance policy start date2010-12-01
Insurance policy end date2010-12-31
Total amount of commissions paid to insurance brokerUSD $193
Total amount of fees paid to insurance companyUSD $15
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH & 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 CarrierUSD $745
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $119
Insurance broker organization code?3
Amount paid for insurance broker fees15
Additional information about fees paid to insurance brokerFEES PAID
Insurance broker nameCBIZ BENEFITS & INSURANCE SERVICES
BLUE CROSS AND BLUE SHIELD OF KANSAS CITY (National Association of Insurance Commissioners NAIC id number: 47171 )
Policy contract number31826000
Policy instance 1
Insurance contract or identification number31826000
Number of Individuals Covered168
Insurance policy start date2010-01-01
Insurance policy end date2010-12-31
Total amount of commissions paid to insurance brokerUSD $12,224
Total amount of fees paid to insurance companyUSD $13,513
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $11,659
Amount paid for insurance broker fees12354
Additional information about fees paid to insurance brokerADMINISTRATIVE SERVICES
Insurance broker organization code?3
Insurance broker nameCBIZ BENEFITS & INSURANCE SERVICES
USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )
Policy contract number1602
Policy instance 4
Insurance contract or identification number1602
Number of Individuals Covered24
Insurance policy start date2010-01-01
Insurance policy end date2010-12-31
Total amount of commissions paid to insurance brokerUSD $258
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH & 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 CarrierUSD $1,035
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $143
Insurance broker organization code?3
Insurance broker nameCBIZ BENEFITS & INSURANCE SERVICES

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