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BUILD-A-BEAR WORKSHOP, INC. WELFARE BENEFITS PLAN 401k Plan overview

Plan NameBUILD-A-BEAR WORKSHOP, INC. WELFARE BENEFITS PLAN
Plan identification number 501

BUILD-A-BEAR WORKSHOP, INC. WELFARE BENEFITS PLAN Benefits

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

401k Sponsoring company profile

BUILD-A-BEAR WORKSHOP, INC. has sponsored the creation of one or more 401k plans.

Company Name:BUILD-A-BEAR WORKSHOP, INC.
Employer identification number (EIN):431883836
NAIC Classification:451120
NAIC Description:Hobby, Toy, and Game Stores

Additional information about BUILD-A-BEAR WORKSHOP, INC.

Jurisdiction of Incorporation: Texas Secretary of State
Incorporation Date: 2000-07-18
Company Identification Number: 0013362006
Legal Registered Office Address: 415 S 18TH ST STE 200

SAINT LOUIS
United States of America (USA)
63103

More information about BUILD-A-BEAR WORKSHOP, INC.

Form 5500 Filing Information

Submission information for form 5500 for 401k plan BUILD-A-BEAR WORKSHOP, INC. WELFARE BENEFITS PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5012022-01-01
5012021-01-01
5012020-01-01
5012019-01-01
5012018-01-01
5012017-01-01JENNIFER GUINN
5012017-01-01JENNIFER GUINN
5012016-01-01JENNIFER GUINN
5012015-01-01JENNIFER GUINN
5012014-01-01JENNIFER GUINN
5012013-01-01TINA KLOCKE
5012012-01-01TINA KLOCKE TINA KLOCKE2013-10-14
5012011-01-01TINA KLOCKE
5012009-01-01TINA KLOCKE TINA KLOCKE2010-10-13

Plan Statistics for BUILD-A-BEAR WORKSHOP, INC. WELFARE BENEFITS PLAN

401k plan membership statisitcs for BUILD-A-BEAR WORKSHOP, INC. WELFARE BENEFITS PLAN

Measure Date Value
2022: BUILD-A-BEAR WORKSHOP, INC. WELFARE BENEFITS PLAN 2022 401k membership
Total participants, beginning-of-year2022-01-011,546
Total number of active participants reported on line 7a of the Form 55002022-01-011,381
Total of all active and inactive participants2022-01-011,381
Total participants2022-01-011,381
2021: BUILD-A-BEAR WORKSHOP, INC. WELFARE BENEFITS PLAN 2021 401k membership
Total participants, beginning-of-year2021-01-011,448
Total number of active participants reported on line 7a of the Form 55002021-01-011,546
Total of all active and inactive participants2021-01-011,546
Total participants2021-01-011,546
2020: BUILD-A-BEAR WORKSHOP, INC. WELFARE BENEFITS PLAN 2020 401k membership
Total participants, beginning-of-year2020-01-011,602
Total number of active participants reported on line 7a of the Form 55002020-01-011,448
Total of all active and inactive participants2020-01-011,448
Total participants2020-01-011,448
2019: BUILD-A-BEAR WORKSHOP, INC. WELFARE BENEFITS PLAN 2019 401k membership
Total participants, beginning-of-year2019-01-011,248
Total number of active participants reported on line 7a of the Form 55002019-01-011,602
Total of all active and inactive participants2019-01-011,602
Total participants2019-01-011,602
2018: BUILD-A-BEAR WORKSHOP, INC. WELFARE BENEFITS PLAN 2018 401k membership
Total participants, beginning-of-year2018-01-011,504
Total number of active participants reported on line 7a of the Form 55002018-01-011,248
Number of retired or separated participants receiving benefits2018-01-010
Number of other retired or separated participants entitled to future benefits2018-01-010
Total of all active and inactive participants2018-01-011,248
2017: BUILD-A-BEAR WORKSHOP, INC. WELFARE BENEFITS PLAN 2017 401k membership
Total participants, beginning-of-year2017-01-011,515
Total number of active participants reported on line 7a of the Form 55002017-01-011,504
Number of retired or separated participants receiving benefits2017-01-010
Number of other retired or separated participants entitled to future benefits2017-01-010
Total of all active and inactive participants2017-01-011,504
2016: BUILD-A-BEAR WORKSHOP, INC. WELFARE BENEFITS PLAN 2016 401k membership
Total participants, beginning-of-year2016-01-011,506
Total number of active participants reported on line 7a of the Form 55002016-01-011,515
Number of retired or separated participants receiving benefits2016-01-010
Number of other retired or separated participants entitled to future benefits2016-01-010
Total of all active and inactive participants2016-01-011,515
Total participants2016-01-011,515
2015: BUILD-A-BEAR WORKSHOP, INC. WELFARE BENEFITS PLAN 2015 401k membership
Total participants, beginning-of-year2015-01-011,534
Total number of active participants reported on line 7a of the Form 55002015-01-011,506
Total of all active and inactive participants2015-01-011,506
2014: BUILD-A-BEAR WORKSHOP, INC. WELFARE BENEFITS PLAN 2014 401k membership
Total participants, beginning-of-year2014-01-011,534
Total number of active participants reported on line 7a of the Form 55002014-01-011,534
Total of all active and inactive participants2014-01-011,534
2013: BUILD-A-BEAR WORKSHOP, INC. WELFARE BENEFITS PLAN 2013 401k membership
Total participants, beginning-of-year2013-01-011,760
Total number of active participants reported on line 7a of the Form 55002013-01-011,534
Total of all active and inactive participants2013-01-011,534
2012: BUILD-A-BEAR WORKSHOP, INC. WELFARE BENEFITS PLAN 2012 401k membership
Total participants, beginning-of-year2012-01-011,760
Total number of active participants reported on line 7a of the Form 55002012-01-011,760
Total of all active and inactive participants2012-01-011,760
2011: BUILD-A-BEAR WORKSHOP, INC. WELFARE BENEFITS PLAN 2011 401k membership
Total participants, beginning-of-year2011-01-011,760
Total number of active participants reported on line 7a of the Form 55002011-01-011,760
Total of all active and inactive participants2011-01-011,760
2009: BUILD-A-BEAR WORKSHOP, INC. WELFARE BENEFITS PLAN 2009 401k membership
Total participants, beginning-of-year2009-01-011,412
Total number of active participants reported on line 7a of the Form 55002009-01-011,783
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 participants2009-01-011,783

Form 5500 Responses for BUILD-A-BEAR WORKSHOP, INC. WELFARE BENEFITS PLAN

2022: BUILD-A-BEAR WORKSHOP, INC. WELFARE BENEFITS PLAN 2022 form 5500 responses
2022-01-01Type of plan entitySingle employer plan
2022-01-01Plan funding arrangement – InsuranceYes
2022-01-01Plan benefit arrangement – InsuranceYes
2021: BUILD-A-BEAR WORKSHOP, INC. WELFARE BENEFITS PLAN 2021 form 5500 responses
2021-01-01Type of plan entitySingle employer plan
2021-01-01Plan funding arrangement – InsuranceYes
2021-01-01Plan benefit arrangement – InsuranceYes
2020: BUILD-A-BEAR WORKSHOP, INC. WELFARE BENEFITS PLAN 2020 form 5500 responses
2020-01-01Type of plan entitySingle employer plan
2020-01-01Plan funding arrangement – InsuranceYes
2020-01-01Plan benefit arrangement – InsuranceYes
2019: BUILD-A-BEAR WORKSHOP, INC. WELFARE BENEFITS PLAN 2019 form 5500 responses
2019-01-01Type of plan entitySingle employer plan
2019-01-01Plan funding arrangement – InsuranceYes
2019-01-01Plan benefit arrangement – InsuranceYes
2018: BUILD-A-BEAR WORKSHOP, INC. WELFARE BENEFITS PLAN 2018 form 5500 responses
2018-01-01Type of plan entitySingle employer plan
2018-01-01Plan funding arrangement – InsuranceYes
2018-01-01Plan benefit arrangement – InsuranceYes
2017: BUILD-A-BEAR WORKSHOP, INC. WELFARE BENEFITS PLAN 2017 form 5500 responses
2017-01-01Type of plan entitySingle employer plan
2017-01-01Submission has been amendedYes
2017-01-01Plan funding arrangement – InsuranceYes
2017-01-01Plan benefit arrangement – InsuranceYes
2016: BUILD-A-BEAR WORKSHOP, INC. WELFARE BENEFITS PLAN 2016 form 5500 responses
2016-01-01Type of plan entitySingle employer plan
2016-01-01Plan funding arrangement – InsuranceYes
2016-01-01Plan benefit arrangement – InsuranceYes
2015: BUILD-A-BEAR WORKSHOP, INC. WELFARE BENEFITS PLAN 2015 form 5500 responses
2015-01-01Type of plan entitySingle employer plan
2015-01-01Plan funding arrangement – InsuranceYes
2015-01-01Plan benefit arrangement – InsuranceYes
2014: BUILD-A-BEAR WORKSHOP, INC. WELFARE BENEFITS PLAN 2014 form 5500 responses
2014-01-01Type of plan entitySingle employer plan
2014-01-01Plan funding arrangement – InsuranceYes
2014-01-01Plan benefit arrangement – InsuranceYes
2013: BUILD-A-BEAR WORKSHOP, INC. WELFARE BENEFITS PLAN 2013 form 5500 responses
2013-01-01Type of plan entitySingle employer plan
2013-01-01Plan funding arrangement – InsuranceYes
2013-01-01Plan benefit arrangement – InsuranceYes
2012: BUILD-A-BEAR WORKSHOP, INC. WELFARE BENEFITS 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: BUILD-A-BEAR WORKSHOP, INC. WELFARE BENEFITS 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
2009: BUILD-A-BEAR WORKSHOP, INC. WELFARE BENEFITS 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

METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number0216820
Policy instance 4
Insurance contract or identification number0216820
Number of Individuals Covered231
Insurance policy start date2021-10-01
Insurance policy end date2022-09-30
Total amount of commissions paid to insurance brokerUSD $1,036
Total amount of fees paid to insurance companyUSD $380
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $16,456
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,036
Amount paid for insurance broker fees323
Additional information about fees paid to insurance brokerSUPPLEMENTAL COMPENSATION
Insurance broker organization code?3
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number0216331
Policy instance 3
Insurance contract or identification number0216331
Number of Individuals Covered1150
Insurance policy start date2021-10-01
Insurance policy end date2022-09-30
Total amount of commissions paid to insurance brokerUSD $52,779
Total amount of fees paid to insurance companyUSD $13,099
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH
Welfare Benefit Premiums Paid to CarrierUSD $472,922
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $23,741
Amount paid for insurance broker fees9638
Additional information about fees paid to insurance brokerSUPPLEMENTAL COMPENSATION
Insurance broker organization code?3
HEALTHY ALLIANCE LIFE INSURANCE COMPANY (G0262) (National Association of Insurance Commissioners NAIC id number: 78972 )
Policy contract numberMO2002
Policy instance 2
Insurance contract or identification numberMO2002
Number of Individuals Covered1083
Insurance policy start date2021-10-01
Insurance policy end date2022-09-30
Total amount of commissions paid to insurance brokerUSD $90,987
Total amount of fees paid to insurance companyUSD $3,336
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $6,508,175
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $90,987
Amount paid for insurance broker fees3336
Additional information about fees paid to insurance brokerINCENTIVES, EDUCATION, COMMUNICATION & TRAINING
Insurance broker organization code?3
CONTINENTAL AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71730 )
Policy contract number0000024652
Policy instance 1
Insurance contract or identification number0000024652
Number of Individuals Covered463
Insurance policy start date2021-10-01
Insurance policy end date2022-09-30
Total amount of commissions paid to insurance brokerUSD $9,057
Total amount of fees paid to insurance companyUSD $0
Temporary Disability Insurance Welfare BenefitYes
Other welfare benefits providedHOSPITAL
Welfare Benefit Premiums Paid to CarrierUSD $60,465
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $9,057
Amount paid for insurance broker fees0
Insurance broker organization code?3
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number0216331
Policy instance 3
Insurance contract or identification number0216331
Number of Individuals Covered1373
Insurance policy start date2020-10-01
Insurance policy end date2021-09-30
Total amount of commissions paid to insurance brokerUSD $65,567
Total amount of fees paid to insurance companyUSD $7,127
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH
Welfare Benefit Premiums Paid to CarrierUSD $579,898
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $33,452
Amount paid for insurance broker fees2704
Additional information about fees paid to insurance brokerSUPPLEMENTAL COMPENSATION
Insurance broker organization code?3
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number0216820
Policy instance 4
Insurance contract or identification number0216820
Number of Individuals Covered173
Insurance policy start date2020-10-01
Insurance policy end date2021-09-30
Total amount of commissions paid to insurance brokerUSD $519
Total amount of fees paid to insurance companyUSD $36
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $14,241
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $519
Amount paid for insurance broker fees5
Additional information about fees paid to insurance brokerSUPPLEMENTAL COMPENSATION
Insurance broker organization code?3
HEALTHY ALLIANCE LIFE INSURANCE COMPANY (G0262) (National Association of Insurance Commissioners NAIC id number: 78972 )
Policy contract numberMO2002
Policy instance 2
Insurance contract or identification numberMO2002
Number of Individuals Covered1140
Insurance policy start date2020-10-01
Insurance policy end date2021-09-30
Total amount of commissions paid to insurance brokerUSD $70,326
Total amount of fees paid to insurance companyUSD $-2,437
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $6,662,314
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $70,326
Amount paid for insurance broker fees-2437
Additional information about fees paid to insurance brokerINCENTIVES, EDUCATION, COMMUNICATION & TRAINING
Insurance broker organization code?3
CONTINENTAL AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71730 )
Policy contract number0000024652
Policy instance 1
Insurance contract or identification number0000024652
Number of Individuals Covered426
Insurance policy start date2020-10-01
Insurance policy end date2021-09-30
Total amount of commissions paid to insurance brokerUSD $7,477
Total amount of fees paid to insurance companyUSD $0
Temporary Disability Insurance Welfare BenefitYes
Other welfare benefits providedHOSPITAL
Welfare Benefit Premiums Paid to CarrierUSD $49,967
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $7,477
Amount paid for insurance broker fees0
Insurance broker organization code?3
HEALTHY ALLIANCE LIFE INSURANCE COMPANY (G0262) (National Association of Insurance Commissioners NAIC id number: 78972 )
Policy contract numberMO2002
Policy instance 2
Insurance contract or identification numberMO2002
Number of Individuals Covered630
Insurance policy start date2019-10-01
Insurance policy end date2020-09-30
Total amount of commissions paid to insurance brokerUSD $58,533
Total amount of fees paid to insurance companyUSD $10,560
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $4,920,110
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $58,533
Amount paid for insurance broker fees10560
Additional information about fees paid to insurance brokerINCENTIVES, EDUCATION, COMMUNICATION & TRAINING
Insurance broker organization code?3
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number0216331
Policy instance 3
Insurance contract or identification number0216331
Number of Individuals Covered1448
Insurance policy start date2019-10-01
Insurance policy end date2020-09-30
Total amount of commissions paid to insurance brokerUSD $134,630
Total amount of fees paid to insurance companyUSD $63,063
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH
Welfare Benefit Premiums Paid to CarrierUSD $1,062,841
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $74,458
Amount paid for insurance broker fees50825
Additional information about fees paid to insurance brokerSUPPLEMENTAL COMPENSATION AND NON-MONETARY COMPENSATION
Insurance broker organization code?3
CONTINENTAL AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71730 )
Policy contract number0000024652
Policy instance 1
Insurance contract or identification number0000024652
Number of Individuals Covered426
Insurance policy start date2019-10-01
Insurance policy end date2020-09-30
Total amount of commissions paid to insurance brokerUSD $10,925
Total amount of fees paid to insurance companyUSD $0
Temporary Disability Insurance Welfare BenefitYes
Other welfare benefits providedHOSPITAL
Welfare Benefit Premiums Paid to CarrierUSD $73,022
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $10,925
Amount paid for insurance broker fees0
Insurance broker organization code?3
CONTINENTAL AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71730 )
Policy contract number0000024652
Policy instance 1
Insurance contract or identification number0000024652
Number of Individuals Covered395
Insurance policy start date2018-10-01
Insurance policy end date2019-09-30
Total amount of commissions paid to insurance brokerUSD $7,316
Total amount of fees paid to insurance companyUSD $0
Temporary Disability Insurance Welfare BenefitYes
Other welfare benefits providedHOSPITAL
Welfare Benefit Premiums Paid to CarrierUSD $48,867
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $7,316
Amount paid for insurance broker fees0
Insurance broker organization code?3
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number0216331
Policy instance 3
Insurance contract or identification number0216331
Number of Individuals Covered1602
Insurance policy start date2018-10-01
Insurance policy end date2019-09-30
Total amount of commissions paid to insurance brokerUSD $51,453
Total amount of fees paid to insurance companyUSD $12,231
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH
Welfare Benefit Premiums Paid to CarrierUSD $1,076,008
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $38,878
Amount paid for insurance broker fees60
Additional information about fees paid to insurance brokerNON-MONETARY COMPENSATION
Insurance broker organization code?3
HEALTHY ALLIANCE LIFE INSURANCE COMPANY (G0262) (National Association of Insurance Commissioners NAIC id number: 78972 )
Policy contract numberMO2002
Policy instance 2
Insurance contract or identification numberMO2002
Number of Individuals Covered684
Insurance policy start date2018-10-01
Insurance policy end date2019-09-30
Total amount of commissions paid to insurance brokerUSD $52,218
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $6,173,388
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $52,218
Amount paid for insurance broker fees0
Insurance broker organization code?3
TRIPLE S (National Association of Insurance Commissioners NAIC id number: 55816 )
Policy contract number12837
Policy instance 1
Insurance contract or identification number12837
Number of Individuals Covered1
Insurance policy start date2018-01-01
Insurance policy end date2018-05-31
Total amount of commissions paid to insurance brokerUSD $2
Total amount of fees paid to insurance companyUSD $0
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $28
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $2
Amount paid for insurance broker fees0
Insurance broker organization code?3
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number0847871
Policy instance 2
Insurance contract or identification number0847871
Number of Individuals Covered1247
Insurance policy start date2017-10-01
Insurance policy end date2018-09-30
Total amount of commissions paid to insurance brokerUSD $111,695
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH, ST DISABILITY
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $111,695
Amount paid for insurance broker fees0
Insurance broker organization code?3
TRIPLE S (National Association of Insurance Commissioners NAIC id number: 55816 )
Policy contract numberSP0001755
Policy instance 1
Insurance contract or identification numberSP0001755
Number of Individuals Covered1
Insurance policy start date2017-02-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $139
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Other welfare benefits providedMAJOR MEDICAL/TRANSPLANT/QUICK HELP
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $139
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameCGF INSURANCE LLC
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number0847871
Policy instance 2
Insurance contract or identification number0847871
Number of Individuals Covered1503
Insurance policy start date2016-10-01
Insurance policy end date2017-09-30
Total amount of commissions paid to insurance brokerUSD $5,700
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH, ST DISABILITY
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,700
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameUSI INSURANCE SERVICES LLC
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number00352295
Policy instance 1
Insurance contract or identification number00352295
Number of Individuals Covered583
Insurance policy start date2014-09-01
Insurance policy end date2015-08-31
Total amount of commissions paid to insurance brokerUSD $13,086
Total amount of fees paid to insurance companyUSD $121
Dental Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $8,776
Amount paid for insurance broker fees121
Additional information about fees paid to insurance brokerPRODUCER BONUS
Insurance broker organization code?3
Insurance broker nameHOLMES MURPHY AND ASSOC INC
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number01016376200000
Policy instance 3
Insurance contract or identification number01016376200000
Number of Individuals Covered1099
Insurance policy start date2014-10-01
Insurance policy end date2015-09-30
Total amount of commissions paid to insurance brokerUSD $4,418
Total amount of fees paid to insurance companyUSD $894
Temporary Disability Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,187
Amount paid for insurance broker fees0
Insurance broker organization code?3
Additional information about fees paid to insurance brokerBROKER BONUS
Insurance broker nameUSI MIDWEST INC
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number01016376000000
Policy instance 4
Insurance contract or identification number01016376000000
Number of Individuals Covered1187
Insurance policy start date2014-10-01
Insurance policy end date2015-09-30
Total amount of commissions paid to insurance brokerUSD $2,754
Total amount of fees paid to insurance companyUSD $134
Life Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,157
Amount paid for insurance broker fees0
Insurance broker organization code?3
Additional information about fees paid to insurance brokerBROKER BONUS
Insurance broker nameHOLMES MURPHY AND ASSOC INC
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number01016376100000
Policy instance 5
Insurance contract or identification number01016376100000
Number of Individuals Covered316
Insurance policy start date2014-10-01
Insurance policy end date2015-09-30
Total amount of commissions paid to insurance brokerUSD $15,257
Total amount of fees paid to insurance companyUSD $519
Long Term Disability Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $7,144
Amount paid for insurance broker fees0
Insurance broker organization code?3
Additional information about fees paid to insurance brokerBROKER BONUS
Insurance broker nameHOLMES MURPHY AND ASSOC INC
TRIPLE S (National Association of Insurance Commissioners NAIC id number: 55816 )
Policy contract numberSP0001755
Policy instance 6
Insurance contract or identification numberSP0001755
Number of Individuals Covered2
Insurance policy start date2015-01-01
Insurance policy end date2015-12-31
Total amount of commissions paid to insurance brokerUSD $255
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Other welfare benefits providedMAJOR MEDICAL
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $255
Amount paid for insurance broker fees0
Insurance broker nameENRIQUE LOPEZ DEL CASTILLO
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number0714842
Policy instance 7
Insurance contract or identification number0714842
Number of Individuals Covered1506
Insurance policy start date2014-10-01
Insurance policy end date2015-09-30
Total amount of commissions paid to insurance brokerUSD $24
Total amount of fees paid to insurance companyUSD $53,393
Health Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $0
Amount paid for insurance broker fees28917
Additional information about fees paid to insurance brokerSERVICE FEE AGREEMENT
Insurance broker organization code?3
Insurance broker nameHOLMES MURPHY AND ASSOC INC
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 32395 )
Policy contract number12316498
Policy instance 8
Insurance contract or identification number12316498
Number of Individuals Covered660
Insurance policy start date2014-09-01
Insurance policy end date2015-08-31
Total amount of commissions paid to insurance brokerUSD $1,012
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,012
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameUSI MIDWEST LLC
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number40000100015595
Policy instance 2
Insurance contract or identification number40000100015595
Number of Individuals Covered404
Insurance policy start date2014-10-01
Insurance policy end date2015-09-30
Total amount of commissions paid to insurance brokerUSD $17,020
Total amount of fees paid to insurance companyUSD $661
Life Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $7,212
Amount paid for insurance broker fees0
Insurance broker organization code?3
Additional information about fees paid to insurance brokerBROKER BONUS
Insurance broker nameHOLMES MURPHY AND ASSOC INC
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 32395 )
Policy contract number12316498
Policy instance 8
Insurance contract or identification number12316498
Number of Individuals Covered652
Insurance policy start date2013-09-01
Insurance policy end date2014-08-31
Total amount of commissions paid to insurance brokerUSD $2,341
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Vision Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,341
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameHOLMES MURPHY AND ASSOC INC
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number0714842
Policy instance 7
Insurance contract or identification number0714842
Number of Individuals Covered1534
Insurance policy start date2013-10-01
Insurance policy end date2014-09-30
Total amount of commissions paid to insurance brokerUSD $-28
Total amount of fees paid to insurance companyUSD $44,344
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Health Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $-28
Amount paid for insurance broker fees44344
Additional information about fees paid to insurance brokerSERVICE FEE AGREEMENT
Insurance broker organization code?3
Insurance broker nameHOLMES MURPHY AND ASSOC INC
TRIPLE S (National Association of Insurance Commissioners NAIC id number: 55816 )
Policy contract numberSP0001755
Policy instance 6
Insurance contract or identification numberSP0001755
Number of Individuals Covered2
Insurance policy start date2013-06-01
Insurance policy end date2014-12-31
Total amount of commissions paid to insurance brokerUSD $810
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Other welfare benefits providedMAJOR MEDICAL
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $810
Amount paid for insurance broker fees0
Insurance broker nameENRIQUE LOPEZ DEL CASTILLO
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number01016376100000
Policy instance 5
Insurance contract or identification number01016376100000
Number of Individuals Covered307
Insurance policy start date2013-10-01
Insurance policy end date2014-09-30
Total amount of commissions paid to insurance brokerUSD $15,314
Total amount of fees paid to insurance companyUSD $7,684
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Long Term Disability Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $15,314
Amount paid for insurance broker fees670
Additional information about fees paid to insurance brokerBROKER BONUS
Insurance broker organization code?3
Insurance broker nameHOLMES MURPHY AND ASSOC INC
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number01016376000000
Policy instance 4
Insurance contract or identification number01016376000000
Number of Individuals Covered1177
Insurance policy start date2013-10-01
Insurance policy end date2014-09-30
Total amount of commissions paid to insurance brokerUSD $2,676
Total amount of fees paid to insurance companyUSD $2,177
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Life Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,676
Amount paid for insurance broker fees192
Additional information about fees paid to insurance brokerBROKER BONUS
Insurance broker organization code?3
Insurance broker nameHOLMES MURPHY AND ASSOC INC
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number01016376200000
Policy instance 3
Insurance contract or identification number01016376200000
Number of Individuals Covered1090
Insurance policy start date2013-10-01
Insurance policy end date2014-09-30
Total amount of commissions paid to insurance brokerUSD $4,371
Total amount of fees paid to insurance companyUSD $14,411
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Temporary Disability Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $0
Amount paid for insurance broker fees13147
Additional information about fees paid to insurance brokerBROKER BONUS
Insurance broker organization code?3
Insurance broker nameHOLMES MURPHY AND ASSOC INC
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number40000100015595
Policy instance 2
Insurance contract or identification number40000100015595
Number of Individuals Covered398
Insurance policy start date2013-10-01
Insurance policy end date2014-09-30
Total amount of commissions paid to insurance brokerUSD $17,300
Total amount of fees paid to insurance companyUSD $10,301
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Life Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $17,300
Amount paid for insurance broker fees892
Additional information about fees paid to insurance brokerBROKER BONUS
Insurance broker organization code?3
Insurance broker nameHOLMES MURPHY AND ASSOC INC
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number00352295
Policy instance 1
Insurance contract or identification number00352295
Number of Individuals Covered568
Insurance policy start date2013-09-01
Insurance policy end date2014-08-31
Total amount of commissions paid to insurance brokerUSD $12,614
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Dental Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $12,614
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameHOLMES MURPHY AND ASSOC INC
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number00352295
Policy instance 1
Insurance contract or identification number00352295
Number of Individuals Covered584
Insurance policy start date2012-09-01
Insurance policy end date2013-08-31
Total amount of commissions paid to insurance brokerUSD $13,886
Total amount of fees paid to insurance companyUSD $3,224
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Dental Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $13,886
Amount paid for insurance broker fees3224
Additional information about fees paid to insurance brokerPRODUCER BONUS
Insurance broker organization code?3
Insurance broker nameHOLMES MURPHY AND ASSOC INC
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number01016376000000
Policy instance 4
Insurance contract or identification number01016376000000
Number of Individuals Covered1185
Insurance policy start date2012-10-01
Insurance policy end date2013-09-30
Total amount of commissions paid to insurance brokerUSD $2,536
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Life Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,536
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameHOLMES MURPHY AND ASSOC INC
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number01016376100000
Policy instance 5
Insurance contract or identification number01016376100000
Number of Individuals Covered320
Insurance policy start date2012-10-01
Insurance policy end date2013-09-30
Total amount of commissions paid to insurance brokerUSD $13,830
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Long Term Disability Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $13,830
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameHOLMES MURPHY AND ASSOC INC
TRIPLE S (National Association of Insurance Commissioners NAIC id number: 55816 )
Policy contract numberSP0001755
Policy instance 6
Insurance contract or identification numberSP0001755
Number of Individuals Covered2
Insurance policy start date2012-06-01
Insurance policy end date2013-05-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Other welfare benefits providedMAJOR MEDICAL
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $0
Amount paid for insurance broker fees0
Insurance broker name
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number0714842
Policy instance 7
Insurance contract or identification number0714842
Number of Individuals Covered1534
Insurance policy start date2012-09-01
Insurance policy end date2013-08-31
Total amount of commissions paid to insurance brokerUSD $34,582
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Health Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $34,582
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameHOLMES MURPHY AND ASSOC INC
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 32395 )
Policy contract number12316498
Policy instance 8
Insurance contract or identification number12316498
Number of Individuals Covered679
Insurance policy start date2012-09-01
Insurance policy end date2013-08-31
Total amount of commissions paid to insurance brokerUSD $2,370
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Vision Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,370
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameHOLMES MURPHY AND ASSOC INC
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number01016376200000
Policy instance 3
Insurance contract or identification number01016376200000
Number of Individuals Covered1085
Insurance policy start date2012-10-01
Insurance policy end date2013-09-30
Total amount of commissions paid to insurance brokerUSD $4,310
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Temporary Disability Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,310
Insurance broker organization code?3
Insurance broker nameHOLMES MURPHY AND ASSOC INC
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number40000100015595
Policy instance 2
Insurance contract or identification number40000100015595
Number of Individuals Covered420
Insurance policy start date2012-10-01
Insurance policy end date2013-09-30
Total amount of commissions paid to insurance brokerUSD $16,331
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Life Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $16,331
Insurance broker organization code?3
Insurance broker nameHOLMES MURPHY AND ASSOC INC
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 32395 )
Policy contract number12316498
Policy instance 1
Insurance contract or identification number12316498
Number of Individuals Covered704
Insurance policy start date2011-09-01
Insurance policy end date2012-08-31
Total amount of commissions paid to insurance brokerUSD $2,282
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 BenefitYes
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 $2,282
Insurance broker organization code?3
Insurance broker nameHOLMES MURPHY & ASSOCIATES, INC.
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number00352295
Policy instance 2
Insurance contract or identification number00352295
Number of Individuals Covered593
Insurance policy start date2011-09-01
Insurance policy end date2012-08-31
Total amount of commissions paid to insurance brokerUSD $15,802
Total amount of fees paid to insurance companyUSD $3,299
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $15,802
Amount paid for insurance broker fees3299
Additional information about fees paid to insurance brokerPRODUCER BONUS
Insurance broker organization code?3
Insurance broker nameHOLMES MURPHY AND ASSOC INC.
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract numberLTD 119798
Policy instance 8
Insurance contract or identification numberLTD 119798
Number of Individuals Covered175
Insurance policy start date2011-10-01
Insurance policy end date2012-09-30
Total amount of commissions paid to insurance brokerUSD $5,036
Total amount of fees paid to insurance companyUSD $1,546
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 $5,036
Amount paid for insurance broker fees1546
Additional information about fees paid to insurance brokerADMINISTRATIVE & OTHER FEES
Insurance broker organization code?3
Insurance broker nameHOLMES MURPHY & ASSOCIATES INC
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number714842
Policy instance 3
Insurance contract or identification number714842
Number of Individuals Covered1760
Insurance policy start date2011-09-01
Insurance policy end date2012-08-31
Total amount of commissions paid to insurance brokerUSD $65,721
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 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 $24,998
Insurance broker organization code?3
Insurance broker nameHOLMES MURPHY & ASSOCIATES
FIRST RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71005 )
Policy contract numberDBL 251576
Policy instance 5
Insurance contract or identification numberDBL 251576
Number of Individuals Covered612
Insurance policy start date2011-10-01
Insurance policy end date2012-09-30
Total amount of commissions paid to insurance brokerUSD $1,664
Total amount of fees paid to insurance companyUSD $228
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 BenefitYes
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 $1,664
Amount paid for insurance broker fees228
Additional information about fees paid to insurance brokerADMINISTRATIVE & OTHER FEES
Insurance broker organization code?3
Insurance broker nameHOLMES MURPHY & ASSOCIATES INC
TRIPLE S (National Association of Insurance Commissioners NAIC id number: 55816 )
Policy contract number114798
Policy instance 4
Insurance contract or identification number114798
Number of Individuals Covered2
Insurance policy start date2011-05-01
Insurance policy end date2012-05-31
Total amount of commissions paid to insurance brokerUSD $0
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 BenefitYes
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
Other welfare benefits providedMAJOR MEDICAL
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 $0
Amount paid for insurance broker fees0
Insurance broker name
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract numberG 160549
Policy instance 6
Insurance contract or identification numberG 160549
Number of Individuals Covered1145
Insurance policy start date2011-10-01
Insurance policy end date2012-09-30
Total amount of commissions paid to insurance brokerUSD $5,341
Total amount of fees paid to insurance companyUSD $3,274
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 BenefitYes
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 $5,341
Amount paid for insurance broker fees3274
Additional information about fees paid to insurance brokerADMINISTRATIVE & OTHER FEES
Insurance broker organization code?3
Insurance broker nameHOLMES MURPHY & ASSOCIATES INC
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract numberGL 146084
Policy instance 7
Insurance contract or identification numberGL 146084
Number of Individuals Covered1307
Insurance policy start date2011-10-01
Insurance policy end date2012-09-30
Total amount of commissions paid to insurance brokerUSD $17,121
Total amount of fees paid to insurance companyUSD $2,549
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 AND 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 $17,121
Amount paid for insurance broker fees2549
Additional information about fees paid to insurance brokerADMINISTRATIVE & OTHER FEES
Insurance broker organization code?3
Insurance broker nameHOLMES MURPHY & ASSOCIATES
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract numberG 160549
Policy instance 3
Insurance contract or identification numberG 160549
Number of Individuals Covered1157
Insurance policy start date2010-10-01
Insurance policy end date2011-09-30
Total amount of commissions paid to insurance brokerUSD $5,395
Total amount of fees paid to insurance companyUSD $8,773
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 BenefitYes
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
FIRST RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71005 )
Policy contract numberDBL 251576
Policy instance 1
Insurance contract or identification numberDBL 251576
Number of Individuals Covered615
Insurance policy start date2010-10-01
Insurance policy end date2011-09-30
Total amount of commissions paid to insurance brokerUSD $1,677
Total amount of fees paid to insurance companyUSD $646
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 BenefitYes
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
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 32395 )
Policy contract number12316498
Policy instance 8
Insurance contract or identification number12316498
Number of Individuals Covered734
Insurance policy start date2010-09-01
Insurance policy end date2011-08-31
Total amount of commissions paid to insurance brokerUSD $2,251
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 BenefitYes
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
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number714842
Policy instance 7
Insurance contract or identification number714842
Number of Individuals Covered1760
Insurance policy start date2010-09-01
Insurance policy end date2011-08-31
Total amount of commissions paid to insurance brokerUSD $114,399
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 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
TRIPLE S (National Association of Insurance Commissioners NAIC id number: 55816 )
Policy contract number114798
Policy instance 6
Insurance contract or identification number114798
Number of Individuals Covered2
Insurance policy start date2011-05-01
Insurance policy end date2012-05-31
Total amount of commissions paid to insurance brokerUSD $0
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 BenefitYes
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
Other welfare benefits providedMAJOR MEDICAL
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
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number00352295
Policy instance 2
Insurance contract or identification number00352295
Number of Individuals Covered635
Insurance policy start date2010-09-01
Insurance policy end date2011-08-31
Total amount of commissions paid to insurance brokerUSD $14,105
Total amount of fees paid to insurance companyUSD $2,877
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract numberGL 146084
Policy instance 4
Insurance contract or identification numberGL 146084
Number of Individuals Covered1317
Insurance policy start date2010-10-01
Insurance policy end date2011-09-30
Total amount of commissions paid to insurance brokerUSD $17,087
Total amount of fees paid to insurance companyUSD $6,434
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 AND 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
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract numberLTD 119798
Policy instance 5
Insurance contract or identification numberLTD 119798
Number of Individuals Covered288
Insurance policy start date2010-10-01
Insurance policy end date2011-09-30
Total amount of commissions paid to insurance brokerUSD $5,035
Total amount of fees paid to insurance companyUSD $3,839
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
FIRST RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71005 )
Policy contract numberDBL 251576
Policy instance 1
Insurance contract or identification numberDBL 251576
Number of Individuals Covered700
Insurance policy start date2009-10-01
Insurance policy end date2010-09-30
Total amount of commissions paid to insurance brokerUSD $1,772
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 BenefitNo
Temporary Disability Insurance Welfare BenefitYes
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
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract numberGL 146084
Policy instance 5
Insurance contract or identification numberGL 146084
Number of Individuals Covered1359
Insurance policy start date2009-10-01
Insurance policy end date2010-09-30
Total amount of commissions paid to insurance brokerUSD $16,041
Total amount of fees paid to insurance companyUSD $548
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 AND 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
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract numberLTD 119798
Policy instance 6
Insurance contract or identification numberLTD 119798
Number of Individuals Covered319
Insurance policy start date2009-10-01
Insurance policy end date2010-09-30
Total amount of commissions paid to insurance brokerUSD $4,957
Total amount of fees paid to insurance companyUSD $334
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
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract numberLTD 119804
Policy instance 7
Insurance contract or identification numberLTD 119804
Number of Individuals Covered37
Insurance policy start date2009-10-01
Insurance policy end date2010-09-30
Total amount of commissions paid to insurance brokerUSD $2,417
Total amount of fees paid to insurance companyUSD $59
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
TRIPLE S (National Association of Insurance Commissioners NAIC id number: 55816 )
Policy contract number1-14798
Policy instance 8
Insurance contract or identification number1-14798
Number of Individuals Covered2
Insurance policy start date2010-05-01
Insurance policy end date2011-04-30
Total amount of commissions paid to insurance brokerUSD $0
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 BenefitYes
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number714842
Policy instance 9
Insurance contract or identification number714842
Number of Individuals Covered1760
Insurance policy start date2009-09-01
Insurance policy end date2010-08-31
Total amount of commissions paid to insurance brokerUSD $52,033
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 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
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 32395 )
Policy contract number12316498
Policy instance 10
Insurance contract or identification number12316498
Number of Individuals Covered715
Insurance policy start date2009-09-01
Insurance policy end date2010-08-31
Total amount of commissions paid to insurance brokerUSD $2,047
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 BenefitYes
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
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number00416740
Policy instance 3
Insurance contract or identification number00416740
Number of Individuals Covered1214
Insurance policy start date2009-09-01
Insurance policy end date2009-09-30
Total amount of commissions paid to insurance brokerUSD $1,276
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
Other welfare benefits providedSHORT TERM DISABILITY (INSURED)
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
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number00352295
Policy instance 2
Insurance contract or identification number00352295
Number of Individuals Covered656
Insurance policy start date2009-09-01
Insurance policy end date2010-08-31
Total amount of commissions paid to insurance brokerUSD $19,745
Total amount of fees paid to insurance companyUSD $3,212
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 BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD & D AND OPTIONAL LIFE
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
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract numberG 160549
Policy instance 4
Insurance contract or identification numberG 160549
Number of Individuals Covered1454
Insurance policy start date2009-10-01
Insurance policy end date2010-09-30
Total amount of commissions paid to insurance brokerUSD $5,210
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 providedSHORT TERM DISABILITY
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

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