FISHBACK FINANCIAL CORPORATION has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan FISHBACK FINANCIAL CORPORATION WRAP PLAN
| Measure | Date | Value |
|---|
| 2022: FISHBACK FINANCIAL CORPORATION WRAP PLAN 2022 401k membership |
|---|
| Total participants, beginning-of-year | 2022-01-01 | 516 |
| Total number of active participants reported on line 7a of the Form 5500 | 2022-01-01 | 518 |
| Number of retired or separated participants receiving benefits | 2022-01-01 | 6 |
| Total of all active and inactive participants | 2022-01-01 | 524 |
| Total participants | 2022-01-01 | 524 |
| 2021: FISHBACK FINANCIAL CORPORATION WRAP PLAN 2021 401k membership |
|---|
| Total participants, beginning-of-year | 2021-01-01 | 503 |
| Total number of active participants reported on line 7a of the Form 5500 | 2021-01-01 | 516 |
| Number of retired or separated participants receiving benefits | 2021-01-01 | 5 |
| Total of all active and inactive participants | 2021-01-01 | 521 |
| Total participants | 2021-01-01 | 521 |
| 2020: FISHBACK FINANCIAL CORPORATION WRAP PLAN 2020 401k membership |
|---|
| Total participants, beginning-of-year | 2020-01-01 | 472 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-01-01 | 503 |
| Number of retired or separated participants receiving benefits | 2020-01-01 | 7 |
| Total of all active and inactive participants | 2020-01-01 | 510 |
| Total participants | 2020-01-01 | 510 |
| 2019: FISHBACK FINANCIAL CORPORATION WRAP PLAN 2019 401k membership |
|---|
| Total participants, beginning-of-year | 2019-01-01 | 466 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-01-01 | 472 |
| Number of retired or separated participants receiving benefits | 2019-01-01 | 7 |
| Total of all active and inactive participants | 2019-01-01 | 479 |
| Total participants | 2019-01-01 | 479 |
| 2018: FISHBACK FINANCIAL CORPORATION WRAP PLAN 2018 401k membership |
|---|
| Total participants, beginning-of-year | 2018-01-01 | 443 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-01-01 | 466 |
| Number of retired or separated participants receiving benefits | 2018-01-01 | 8 |
| Total of all active and inactive participants | 2018-01-01 | 474 |
| Total participants | 2018-01-01 | 474 |
| 2017: FISHBACK FINANCIAL CORPORATION WRAP PLAN 2017 401k membership |
|---|
| Total participants, beginning-of-year | 2017-01-01 | 388 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-01-01 | 404 |
| Number of retired or separated participants receiving benefits | 2017-01-01 | 3 |
| Total of all active and inactive participants | 2017-01-01 | 407 |
| Total participants | 2017-01-01 | 407 |
| 2016: FISHBACK FINANCIAL CORPORATION WRAP PLAN 2016 401k membership |
|---|
| Total participants, beginning-of-year | 2016-01-01 | 390 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-01-01 | 409 |
| Total of all active and inactive participants | 2016-01-01 | 409 |
| Total participants | 2016-01-01 | 409 |
| 2015: FISHBACK FINANCIAL CORPORATION WRAP PLAN 2015 401k membership |
|---|
| Total participants, beginning-of-year | 2015-01-01 | 402 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-01-01 | 383 |
| Total of all active and inactive participants | 2015-01-01 | 383 |
| Total participants | 2015-01-01 | 383 |
| 2014: FISHBACK FINANCIAL CORPORATION WRAP PLAN 2014 401k membership |
|---|
| Total participants, beginning-of-year | 2014-01-01 | 379 |
| Total number of active participants reported on line 7a of the Form 5500 | 2014-01-01 | 386 |
| Number of retired or separated participants receiving benefits | 2014-01-01 | 3 |
| Number of other retired or separated participants entitled to future benefits | 2014-01-01 | 0 |
| Total of all active and inactive participants | 2014-01-01 | 389 |
| Total participants | 2014-01-01 | 389 |
| 2013: FISHBACK FINANCIAL CORPORATION WRAP PLAN 2013 401k membership |
|---|
| Total participants, beginning-of-year | 2013-01-01 | 435 |
| Total number of active participants reported on line 7a of the Form 5500 | 2013-01-01 | 420 |
| Number of retired or separated participants receiving benefits | 2013-01-01 | 9 |
| Number of other retired or separated participants entitled to future benefits | 2013-01-01 | 0 |
| Total of all active and inactive participants | 2013-01-01 | 429 |
| Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits | 2013-01-01 | 0 |
| Total participants | 2013-01-01 | 429 |
| Number of participants with account balances | 2013-01-01 | 0 |
| Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested | 2013-01-01 | 0 |
| Number of employers contributing to the scheme | 2013-01-01 | 0 |
| 2012: FISHBACK FINANCIAL CORPORATION WRAP PLAN 2012 401k membership |
|---|
| Total participants, beginning-of-year | 2012-01-01 | 423 |
| Total number of active participants reported on line 7a of the Form 5500 | 2012-01-01 | 433 |
| Number of retired or separated participants receiving benefits | 2012-01-01 | 2 |
| Number of other retired or separated participants entitled to future benefits | 2012-01-01 | 0 |
| Total of all active and inactive participants | 2012-01-01 | 435 |
| Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits | 2012-01-01 | 0 |
| Total participants | 2012-01-01 | 435 |
| Number of participants with account balances | 2012-01-01 | 0 |
| Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested | 2012-01-01 | 0 |
| Number of employers contributing to the scheme | 2012-01-01 | 0 |
| 2011: FISHBACK FINANCIAL CORPORATION WRAP PLAN 2011 401k membership |
|---|
| Total participants, beginning-of-year | 2011-01-01 | 399 |
| Total number of active participants reported on line 7a of the Form 5500 | 2011-01-01 | 408 |
| Number of retired or separated participants receiving benefits | 2011-01-01 | 2 |
| Total of all active and inactive participants | 2011-01-01 | 410 |
| Total participants | 2011-01-01 | 410 |
| 2009: FISHBACK FINANCIAL CORPORATION WRAP PLAN 2009 401k membership |
|---|
| Total participants, beginning-of-year | 2009-01-01 | 393 |
| Total number of active participants reported on line 7a of the Form 5500 | 2009-01-01 | 342 |
| Number of retired or separated participants receiving benefits | 2009-01-01 | 3 |
| Number of other retired or separated participants entitled to future benefits | 2009-01-01 | 0 |
| Total of all active and inactive participants | 2009-01-01 | 345 |
| 2022: FISHBACK FINANCIAL CORPORATION WRAP PLAN 2022 form 5500 responses |
|---|
| 2022-01-01 | Type of plan entity | Single employer plan |
| 2022-01-01 | Submission has been amended | No |
| 2022-01-01 | This submission is the final filing | No |
| 2022-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2022-01-01 | Plan is a collectively bargained plan | No |
| 2022-01-01 | Plan funding arrangement – Insurance | Yes |
| 2022-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2022-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2022-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2021: FISHBACK FINANCIAL CORPORATION WRAP PLAN 2021 form 5500 responses |
|---|
| 2021-01-01 | Type of plan entity | Single employer plan |
| 2021-01-01 | Submission has been amended | No |
| 2021-01-01 | This submission is the final filing | No |
| 2021-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2021-01-01 | Plan is a collectively bargained plan | No |
| 2021-01-01 | Plan funding arrangement – Insurance | Yes |
| 2021-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2021-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2021-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2020: FISHBACK FINANCIAL CORPORATION WRAP PLAN 2020 form 5500 responses |
|---|
| 2020-01-01 | Type of plan entity | Single employer plan |
| 2020-01-01 | Submission has been amended | No |
| 2020-01-01 | This submission is the final filing | No |
| 2020-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2020-01-01 | Plan is a collectively bargained plan | No |
| 2020-01-01 | Plan funding arrangement – Insurance | Yes |
| 2020-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2020-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2020-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2019: FISHBACK FINANCIAL CORPORATION WRAP PLAN 2019 form 5500 responses |
|---|
| 2019-01-01 | Type of plan entity | Single employer plan |
| 2019-01-01 | Submission has been amended | No |
| 2019-01-01 | This submission is the final filing | No |
| 2019-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2019-01-01 | Plan is a collectively bargained plan | No |
| 2019-01-01 | Plan funding arrangement – Insurance | Yes |
| 2019-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2019-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2019-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2018: FISHBACK FINANCIAL CORPORATION WRAP PLAN 2018 form 5500 responses |
|---|
| 2018-01-01 | Type of plan entity | Single employer plan |
| 2018-01-01 | Submission has been amended | No |
| 2018-01-01 | This submission is the final filing | No |
| 2018-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2018-01-01 | Plan is a collectively bargained plan | No |
| 2018-01-01 | Plan funding arrangement – Insurance | Yes |
| 2018-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2018-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2018-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2017: FISHBACK FINANCIAL CORPORATION WRAP PLAN 2017 form 5500 responses |
|---|
| 2017-01-01 | Type of plan entity | Single employer plan |
| 2017-01-01 | Submission has been amended | No |
| 2017-01-01 | This submission is the final filing | No |
| 2017-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2017-01-01 | Plan is a collectively bargained plan | No |
| 2017-01-01 | Plan funding arrangement – Insurance | Yes |
| 2017-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2017-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2017-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2016: FISHBACK FINANCIAL CORPORATION WRAP PLAN 2016 form 5500 responses |
|---|
| 2016-01-01 | Type of plan entity | Single employer plan |
| 2016-01-01 | Submission has been amended | No |
| 2016-01-01 | This submission is the final filing | No |
| 2016-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2016-01-01 | Plan is a collectively bargained plan | No |
| 2016-01-01 | Plan funding arrangement – Insurance | Yes |
| 2016-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2016-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2016-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2015: FISHBACK FINANCIAL CORPORATION WRAP PLAN 2015 form 5500 responses |
|---|
| 2015-01-01 | Type of plan entity | Single employer plan |
| 2015-01-01 | Submission has been amended | No |
| 2015-01-01 | This submission is the final filing | No |
| 2015-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2015-01-01 | Plan is a collectively bargained plan | No |
| 2015-01-01 | Plan funding arrangement – Insurance | Yes |
| 2015-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2015-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2015-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2014: FISHBACK FINANCIAL CORPORATION WRAP PLAN 2014 form 5500 responses |
|---|
| 2014-01-01 | Type of plan entity | Single employer plan |
| 2014-01-01 | Plan funding arrangement – Insurance | Yes |
| 2014-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2014-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2014-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2013: FISHBACK FINANCIAL CORPORATION WRAP PLAN 2013 form 5500 responses |
|---|
| 2013-01-01 | Type of plan entity | Single employer plan |
| 2013-01-01 | First time form 5500 has been submitted | Yes |
| 2013-01-01 | Submission has been amended | No |
| 2013-01-01 | This submission is the final filing | No |
| 2013-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2013-01-01 | Plan is a collectively bargained plan | No |
| 2013-01-01 | Plan funding arrangement – Insurance | Yes |
| 2013-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2012: FISHBACK FINANCIAL CORPORATION WRAP PLAN 2012 form 5500 responses |
|---|
| 2012-01-01 | Type of plan entity | Single employer plan |
| 2012-01-01 | Submission has been amended | No |
| 2012-01-01 | This submission is the final filing | No |
| 2012-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2012-01-01 | Plan is a collectively bargained plan | No |
| 2012-01-01 | Plan funding arrangement – Insurance | Yes |
| 2012-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2011: FISHBACK FINANCIAL CORPORATION WRAP PLAN 2011 form 5500 responses |
|---|
| 2011-01-01 | Type of plan entity | Single employer plan |
| 2011-01-01 | Submission has been amended | No |
| 2011-01-01 | This submission is the final filing | No |
| 2011-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2011-01-01 | Plan is a collectively bargained plan | No |
| 2011-01-01 | Plan funding arrangement – Insurance | Yes |
| 2011-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2009: FISHBACK FINANCIAL CORPORATION WRAP PLAN 2009 form 5500 responses |
|---|
| 2009-01-01 | Type of plan entity | Single employer plan |
| 2009-01-01 | Submission has been amended | No |
| 2009-01-01 | This submission is the final filing | No |
| 2009-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2009-01-01 | Plan is a collectively bargained plan | No |
| 2009-01-01 | Plan funding arrangement – Insurance | Yes |
| 2009-01-01 | Plan benefit arrangement – Insurance | Yes |
| AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 ) |
| Policy contract number | C9913 |
| Policy instance | 5 |
| Insurance contract or identification number | C9913 | | Number of Individuals Covered | 322 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $43,153 | | Total amount of fees paid to insurance company | USD $277 | | Other welfare benefits provided | CANCER, ACCIDENT INS, HOSP INDEMN | | Welfare Benefit Premiums Paid to Carrier | USD $311,659 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $11,309 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 108 | | Additional information about fees paid to insurance broker | MISC FEES |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GVTL0B68H |
| Policy instance | 4 |
| Insurance contract or identification number | GVTL0B68H | | Number of Individuals Covered | 97 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2023-01-01 | | Total amount of commissions paid to insurance broker | USD $7,366 | | Total amount of fees paid to insurance company | USD $5,164 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $69,874 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 5164 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 | | Commission paid to Insurance Broker | USD $7,366 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG0B68H |
| Policy instance | 3 |
| Insurance contract or identification number | GLUG0B68H | | Number of Individuals Covered | 292 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2023-01-01 | | Total amount of commissions paid to insurance broker | USD $3,748 | | Total amount of fees paid to insurance company | USD $3,090 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $44,883 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 3090 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 | | Commission paid to Insurance Broker | USD $3,748 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLTD0B68H |
| Policy instance | 2 |
| Insurance contract or identification number | GLTD0B68H | | Number of Individuals Covered | 290 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2023-01-01 | | Total amount of commissions paid to insurance broker | USD $4,522 | | Total amount of fees paid to insurance company | USD $4,448 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $62,352 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 4448 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 | | Commission paid to Insurance Broker | USD $4,522 |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 30070840 |
| Policy instance | 1 |
| Insurance contract or identification number | 30070840 | | Number of Individuals Covered | 516 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $1,139 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $21,119 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,139 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GVTL0B68H |
| Policy instance | 1 |
| Insurance contract or identification number | GVTL0B68H | | Number of Individuals Covered | 173 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2022-01-01 | | Total amount of commissions paid to insurance broker | USD $7,895 | | Total amount of fees paid to insurance company | USD $3,861 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $73,775 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,895 | | Amount paid for insurance broker fees | 3861 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 30070840 |
| Policy instance | 2 |
| Insurance contract or identification number | 30070840 | | Number of Individuals Covered | 514 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $1,123 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $20,568 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,123 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLTD0B68H |
| Policy instance | 3 |
| Insurance contract or identification number | GLTD0B68H | | Number of Individuals Covered | 623 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2022-01-01 | | Total amount of commissions paid to insurance broker | USD $4,771 | | Total amount of fees paid to insurance company | USD $3,501 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $63,546 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,771 | | Amount paid for insurance broker fees | 3501 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 ) |
| Policy contract number | C9913 |
| Policy instance | 4 |
| Insurance contract or identification number | C9913 | | Number of Individuals Covered | 339 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $43,545 | | Total amount of fees paid to insurance company | USD $1,165 | | Other welfare benefits provided | CANCER, ACCIDENT INS, HOSP INDEMN | | Welfare Benefit Premiums Paid to Carrier | USD $365,358 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $11,159 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 31 | | Additional information about fees paid to insurance broker | MISC FEES |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG0B68H |
| Policy instance | 5 |
| Insurance contract or identification number | GLUG0B68H | | Number of Individuals Covered | 623 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2022-01-01 | | Total amount of commissions paid to insurance broker | USD $3,790 | | Total amount of fees paid to insurance company | USD $2,488 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $44,143 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,790 | | Amount paid for insurance broker fees | 2488 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 30070840 |
| Policy instance | 1 |
| Insurance contract or identification number | 30070840 | | Number of Individuals Covered | 502 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $1,105 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $19,976 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,105 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLTD0B68H |
| Policy instance | 2 |
| Insurance contract or identification number | GLTD0B68H | | Number of Individuals Covered | 609 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2021-01-01 | | Total amount of commissions paid to insurance broker | USD $4,662 | | Total amount of fees paid to insurance company | USD $3,896 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $58,346 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,662 | | Amount paid for insurance broker fees | 3896 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GVTL0B68H |
| Policy instance | 3 |
| Insurance contract or identification number | GVTL0B68H | | Number of Individuals Covered | 160 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2021-01-01 | | Total amount of commissions paid to insurance broker | USD $7,287 | | Total amount of fees paid to insurance company | USD $4,063 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $64,350 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,287 | | Amount paid for insurance broker fees | 4063 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 ) |
| Policy contract number | C9913 |
| Policy instance | 4 |
| Insurance contract or identification number | C9913 | | Number of Individuals Covered | 352 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $45,871 | | Total amount of fees paid to insurance company | USD $1,274 | | Other welfare benefits provided | CANCER, ACCIDENT INS, HOSP INDEMN | | Welfare Benefit Premiums Paid to Carrier | USD $317,236 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,533 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 27 | | Additional information about fees paid to insurance broker | MISC FEES |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG0B68H |
| Policy instance | 5 |
| Insurance contract or identification number | GLUG0B68H | | Number of Individuals Covered | 610 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2021-01-01 | | Total amount of commissions paid to insurance broker | USD $3,630 | | Total amount of fees paid to insurance company | USD $2,798 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $41,475 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,630 | | Amount paid for insurance broker fees | 2798 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 30070840 |
| Policy instance | 4 |
| Insurance contract or identification number | 30070840 | | Number of Individuals Covered | 493 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $983 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $19,870 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $983 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLTD0B68H |
| Policy instance | 5 |
| Insurance contract or identification number | GLTD0B68H | | Number of Individuals Covered | 589 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2020-01-01 | | Total amount of commissions paid to insurance broker | USD $4,638 | | Total amount of fees paid to insurance company | USD $3,126 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $55,650 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,638 | | Amount paid for insurance broker fees | 3126 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 ) |
| Policy contract number | C9913 |
| Policy instance | 3 |
| Insurance contract or identification number | C9913 | | Number of Individuals Covered | 381 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $53,729 | | Total amount of fees paid to insurance company | USD $1,798 | | Other welfare benefits provided | CANCER, ACCIDENT INS, HOSP INDEMN | | Welfare Benefit Premiums Paid to Carrier | USD $366,567 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $10,965 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 100 | | Additional information about fees paid to insurance broker | MISC FEES |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GVTL0B68H |
| Policy instance | 2 |
| Insurance contract or identification number | GVTL0B68H | | Number of Individuals Covered | 149 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2020-01-01 | | Total amount of commissions paid to insurance broker | USD $6,831 | | Total amount of fees paid to insurance company | USD $3,346 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $58,043 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,831 | | Amount paid for insurance broker fees | 3346 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG0B68H |
| Policy instance | 1 |
| Insurance contract or identification number | GLUG0B68H | | Number of Individuals Covered | 590 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2020-01-01 | | Total amount of commissions paid to insurance broker | USD $3,554 | | Total amount of fees paid to insurance company | USD $2,281 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $39,977 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,554 | | Amount paid for insurance broker fees | 2281 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 ) |
| Policy contract number | C9913 |
| Policy instance | 5 |
| Insurance contract or identification number | C9913 | | Number of Individuals Covered | 384 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $41,407 | | Total amount of fees paid to insurance company | USD $1,037 | | Other welfare benefits provided | CANCER, ACCIDENT INS, HOSP INDEMN | | Welfare Benefit Premiums Paid to Carrier | USD $250,271 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $9,034 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 37 | | Additional information about fees paid to insurance broker | MISC FEES |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLTD0B68H |
| Policy instance | 4 |
| Insurance contract or identification number | GLTD0B68H | | Number of Individuals Covered | 573 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2019-01-01 | | Total amount of commissions paid to insurance broker | USD $4,605 | | Total amount of fees paid to insurance company | USD $956 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $52,098 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,605 | | Amount paid for insurance broker fees | 956 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 30070840 |
| Policy instance | 3 |
| Insurance contract or identification number | 30070840 | | Number of Individuals Covered | 485 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $1,066 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $18,882 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,066 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG0B68H |
| Policy instance | 2 |
| Insurance contract or identification number | GLUG0B68H | | Number of Individuals Covered | 574 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2019-01-01 | | Total amount of commissions paid to insurance broker | USD $3,603 | | Total amount of fees paid to insurance company | USD $719 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $38,009 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,603 | | Amount paid for insurance broker fees | 719 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GVTL0B68H |
| Policy instance | 1 |
| Insurance contract or identification number | GVTL0B68H | | Number of Individuals Covered | 149 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2019-01-01 | | Total amount of commissions paid to insurance broker | USD $6,725 | | Total amount of fees paid to insurance company | USD $1,045 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $55,769 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,725 | | Amount paid for insurance broker fees | 1045 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GVTL0B68H |
| Policy instance | 1 |
| Insurance contract or identification number | GVTL0B68H | | Number of Individuals Covered | 144 | | Insurance policy start date | 2017-05-01 | | Insurance policy end date | 2018-01-01 | | Total amount of commissions paid to insurance broker | USD $4,951 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $35,006 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,951 | | Insurance broker organization code? | 3 | | Insurance broker name | SILVERSTONE GROUP, INC. |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 30070840 |
| Policy instance | 2 |
| Insurance contract or identification number | 30070840 | | Number of Individuals Covered | 423 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $981 | | Welfare Benefit Premiums Paid to Carrier | USD $16,488 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $981 | | Insurance broker organization code? | 3 | | Insurance broker name | SILVERSTONE GROUP |
|
| AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 ) |
| Policy contract number | C9913 |
| Policy instance | 3 |
| Insurance contract or identification number | C9913 | | Number of Individuals Covered | 390 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $43,646 | | Total amount of fees paid to insurance company | USD $878 | | Other welfare benefits provided | CANCER, ACCIDENT INS, HOSP INDEMN | | Welfare Benefit Premiums Paid to Carrier | USD $298,846 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $9,177 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 33 | | Additional information about fees paid to insurance broker | MISC FEES | | Insurance broker name | MELODY B. THOMPSON |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG0B68H |
| Policy instance | 4 |
| Insurance contract or identification number | GLUG0B68H | | Number of Individuals Covered | 489 | | Insurance policy start date | 2107-05-01 | | Insurance policy end date | 2018-01-01 | | Total amount of commissions paid to insurance broker | USD $2,156 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $21,565 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,156 | | Insurance broker organization code? | 3 | | Insurance broker name | SILVERSTONE GROUP, INC. |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLTD0B68H |
| Policy instance | 6 |
| Insurance contract or identification number | GLTD0B68H | | Number of Individuals Covered | 488 | | Insurance policy start date | 2017-05-01 | | Insurance policy end date | 2018-01-01 | | Total amount of commissions paid to insurance broker | USD $3,444 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $28,884 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,444 | | Insurance broker organization code? | 3 | | Insurance broker name | SILVERSTONE GROUP, INC |
|
| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
| Policy contract number | 874428G |
| Policy instance | 5 |
| Insurance contract or identification number | 874428G | | Number of Individuals Covered | 475 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $1,013 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | DEP LIFE, VOLUNTARY DEP LIFE | | Welfare Benefit Premiums Paid to Carrier | USD $36,796 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,013 | | Insurance broker organization code? | 3 | | Insurance broker name | SILVERSTONE GROUP, INC |
|
| AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 ) |
| Policy contract number | C9913 |
| Policy instance | 1 |
| Insurance contract or identification number | C9913 | | Number of Individuals Covered | 348 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $42,893 | | Total amount of fees paid to insurance company | USD $1,242 | | Other welfare benefits provided | CANCER, ACCIDENT INS, HOSP INDEMN | | Welfare Benefit Premiums Paid to Carrier | USD $305,565 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,143 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 207 | | Additional information about fees paid to insurance broker | MISC FEES | | Insurance broker name | MATTHEW D BUTLER |
|
| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
| Policy contract number | 874428G |
| Policy instance | 2 |
| Insurance contract or identification number | 874428G | | Number of Individuals Covered | 427 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $10,001 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | DEP LIFE, VOLUNTARY DEP LIFE | | Welfare Benefit Premiums Paid to Carrier | USD $98,900 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $10,001 | | Insurance broker organization code? | 3 | | Insurance broker name | SILVERSTONE GROUP, INC |
|
| SUN LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80926 ) |
| Policy contract number | 246-6827-00 |
| Policy instance | 4 |
| Insurance contract or identification number | 246-6827-00 | | Number of Individuals Covered | 433 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-04-30 | | Total amount of commissions paid to insurance broker | USD $6,059 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | DEP LIFE, VOLUNTARY DEP LIFE | | Welfare Benefit Premiums Paid to Carrier | USD $39,526 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,059 | | Insurance broker organization code? | 3 | | Insurance broker name | AVERA HEALTH PLANS INC |
|
| AVERA HEALTH PLANS, INC. (National Association of Insurance Commissioners NAIC id number: 95839 ) |
| Policy contract number | FFC1 |
| Policy instance | 3 |
| Insurance contract or identification number | FFC1 | | Number of Individuals Covered | 901 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $28,508 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 ) |
| Policy contract number | C9913 |
| Policy instance | 2 |
| Insurance contract or identification number | C9913 | | Number of Individuals Covered | 329 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $33,158 | | Total amount of fees paid to insurance company | USD $1,524 | | Other welfare benefits provided | CANCER, ACCIDENT INS, HOSP INDEMN | | Welfare Benefit Premiums Paid to Carrier | USD $212,228 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,353 | | Amount paid for insurance broker fees | 13 | | Additional information about fees paid to insurance broker | MISC FEES | | Insurance broker organization code? | 3 | | Insurance broker name | JESSE A REISCH |
|
| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
| Policy contract number | 874428G |
| Policy instance | 1 |
| Insurance contract or identification number | 874428G | | Number of Individuals Covered | 441 | | Insurance policy start date | 2014-05-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $8,343 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | DEP LIFE, VOLUNTARY DEP LIFE | | Welfare Benefit Premiums Paid to Carrier | USD $64,422 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,343 | | Insurance broker organization code? | 3 | | Insurance broker name | SILVERSTONE GROUP, INC |
|
| AVERA HEALTH PLANS, INC. (National Association of Insurance Commissioners NAIC id number: 95839 ) |
| Policy contract number | FFC1 |
| Policy instance | 1 |
| Insurance contract or identification number | FFC1 | | Number of Individuals Covered | 1059 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $158,084 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $158,084 | | Additional information about fees paid to insurance broker | THIRD PARTY ADMINISTRATION FEES | | Insurance broker organization code? | 5 | | Insurance broker name | AVERA HEALTH PLANS |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 225413 |
| Policy instance | 2 |
| Insurance contract or identification number | 225413 | | Number of Individuals Covered | 354 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $9,292 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $9,292 | | Additional information about fees paid to insurance broker | STOP LOSS SPECIFIC | | Insurance broker organization code? | 3 | | Insurance broker name | AVERA HEALTH PLANS |
|
| SUN LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80926 ) |
| Policy contract number | 246-6827-00 |
| Policy instance | 3 |
| Insurance contract or identification number | 246-6827-00 | | Number of Individuals Covered | 420 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $11,481 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | DEPENDENT LIFE, VOLUNTARY, VOLUNTARY DEPENDENT LIFE | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $110,157 | | Commission paid to Insurance Broker | USD $11,481 | | Additional information about fees paid to insurance broker | LIFE, LTD, DEPENDENT LIFE, VOLUNTARY & VOLUNTARY DEPENDENT LIFE | | Insurance broker name | AVERA HEALTH PLANS, INC |
|
| SUN LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80926 ) |
| Policy contract number | 246-6827-00 |
| Policy instance | 2 |
| Insurance contract or identification number | 246-6827-00 | | Number of Individuals Covered | 415 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2013-01-01 | | Total amount of commissions paid to insurance broker | USD $11,107 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | DEPENDENT LIFE; VOLUNTARY DEPENDENT LIFE | | Welfare Benefit Premiums Paid to Carrier | USD $103,050 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $11,107 | | Insurance broker name | AVERA HEALTH PLANS, INC |
|
| AVERA HEALTH PLANS, INC. (National Association of Insurance Commissioners NAIC id number: 95839 ) |
| Policy contract number | FFC1 |
| Policy instance | 1 |
| Insurance contract or identification number | FFC1 | | Number of Individuals Covered | 1038 | | Insurance policy start date | 2012-01-01 | | Insurance policy end date | 2012-12-31 | | Total amount of commissions paid to insurance broker | USD $159,344 | | Health Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $159,344 | | Additional information about fees paid to insurance broker | THIRD PARTY ADMINISTRATION FEES | | Insurance broker organization code? | 5 | | Insurance broker name | AVERA HEALTH PLANS, INC |
|
