PRIME GROUP HOLDINGS, LLC has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan PRIME GROUP HOLDINGS HEALTH BENEFIT PLAN
| Measure | Date | Value |
|---|
| 2021 : PRIME GROUP HOLDINGS HEALTH BENEFIT PLAN 2021 401k financial data |
|---|
| Total unrealized appreciation/depreciation of assets | 2021-12-31 | $0 |
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2021-12-31 | $75,203 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2021-12-31 | $0 |
| Total income from all sources (including contributions) | 2021-12-31 | $75,203 |
| Total loss/gain on sale of assets | 2021-12-31 | $0 |
| Total of all expenses incurred | 2021-12-31 | $75,203 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2021-12-31 | $75,203 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2021-12-31 | $75,203 |
| Value of total assets at end of year | 2021-12-31 | $75,203 |
| Value of total assets at beginning of year | 2021-12-31 | $0 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2021-12-31 | $0 |
| Total interest from all sources | 2021-12-31 | $0 |
| Total dividends received (eg from common stock, registered investment company shares) | 2021-12-31 | $0 |
| Was this plan covered by a fidelity bond | 2021-12-31 | No |
| Contributions received from participants | 2021-12-31 | $69,830 |
| Participant contributions at end of year | 2021-12-31 | $69,830 |
| Income. Received or receivable in cash from other sources (including rollovers) | 2021-12-31 | $5,373 |
| Expenses. Other payments made (not to insurance carriers or or participants/beneficiaries) | 2021-12-31 | $6,503 |
| Value of other receiveables (less allowance for doubtful accounts) at end of year | 2021-12-31 | $5,373 |
| Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year | 2021-12-31 | $6,503 |
| Value of net income/loss | 2021-12-31 | $0 |
| Value of net assets at end of year (total assets less liabilities) | 2021-12-31 | $0 |
| Value of net assets at beginning of year (total assets less liabilities) | 2021-12-31 | $0 |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2021-12-31 | No |
| Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers | 2021-12-31 | $68,700 |
| Liabilities. Value of benefit claims payable at end of year | 2021-12-31 | $68,700 |
| 2020 : PRIME GROUP HOLDINGS HEALTH BENEFIT PLAN 2020 401k financial data |
|---|
| Total unrealized appreciation/depreciation of assets | 2020-12-31 | $0 |
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2020-12-31 | $236,973 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2020-12-31 | $0 |
| Total income from all sources (including contributions) | 2020-12-31 | $11,815 |
| Total loss/gain on sale of assets | 2020-12-31 | $0 |
| Total of all expenses incurred | 2020-12-31 | $236,973 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2020-12-31 | $236,973 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2020-12-31 | $11,815 |
| Value of total assets at end of year | 2020-12-31 | $676,069 |
| Value of total assets at beginning of year | 2020-12-31 | $664,254 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2020-12-31 | $0 |
| Total interest from all sources | 2020-12-31 | $0 |
| Total dividends received (eg from common stock, registered investment company shares) | 2020-12-31 | $0 |
| Was this plan covered by a fidelity bond | 2020-12-31 | No |
| Contributions received from participants | 2020-12-31 | $8,667 |
| Participant contributions at end of year | 2020-12-31 | $8,667 |
| Income. Received or receivable in cash from other sources (including rollovers) | 2020-12-31 | $3,148 |
| Value of other receiveables (less allowance for doubtful accounts) at end of year | 2020-12-31 | $3,148 |
| Total non interest bearing cash at end of year | 2020-12-31 | $664,254 |
| Total non interest bearing cash at beginning of year | 2020-12-31 | $664,254 |
| Value of net income/loss | 2020-12-31 | $-225,158 |
| Value of net assets at end of year (total assets less liabilities) | 2020-12-31 | $439,096 |
| Value of net assets at beginning of year (total assets less liabilities) | 2020-12-31 | $664,254 |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2020-12-31 | No |
| Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers | 2020-12-31 | $236,973 |
| Liabilities. Value of benefit claims payable at end of year | 2020-12-31 | $236,973 |
| 2019 : PRIME GROUP HOLDINGS HEALTH BENEFIT PLAN 2019 401k financial data |
|---|
| Total unrealized appreciation/depreciation of assets | 2019-12-31 | $0 |
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2019-12-31 | $313,264 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2019-12-31 | $0 |
| Total income from all sources (including contributions) | 2019-12-31 | $46,539 |
| Total loss/gain on sale of assets | 2019-12-31 | $0 |
| Total of all expenses incurred | 2019-12-31 | $313,264 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2019-12-31 | $313,264 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2019-12-31 | $46,539 |
| Value of total assets at end of year | 2019-12-31 | $767,571 |
| Value of total assets at beginning of year | 2019-12-31 | $721,032 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2019-12-31 | $0 |
| Total interest from all sources | 2019-12-31 | $0 |
| Total dividends received (eg from common stock, registered investment company shares) | 2019-12-31 | $0 |
| Was this plan covered by a fidelity bond | 2019-12-31 | No |
| Contributions received from participants | 2019-12-31 | $11,349 |
| Participant contributions at end of year | 2019-12-31 | $11,349 |
| Income. Received or receivable in cash from other sources (including rollovers) | 2019-12-31 | $35,190 |
| Value of other receiveables (less allowance for doubtful accounts) at end of year | 2019-12-31 | $35,190 |
| Total non interest bearing cash at end of year | 2019-12-31 | $721,032 |
| Total non interest bearing cash at beginning of year | 2019-12-31 | $721,032 |
| Value of net income/loss | 2019-12-31 | $-266,725 |
| Value of net assets at end of year (total assets less liabilities) | 2019-12-31 | $454,307 |
| Value of net assets at beginning of year (total assets less liabilities) | 2019-12-31 | $721,032 |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2019-12-31 | No |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2019-12-31 | $268,823 |
| Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers | 2019-12-31 | $44,441 |
| Liabilities. Value of benefit claims payable at end of year | 2019-12-31 | $313,264 |
| 2018 : PRIME GROUP HOLDINGS HEALTH BENEFIT PLAN 2018 401k financial data |
|---|
| Total unrealized appreciation/depreciation of assets | 2018-12-31 | $0 |
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2018-12-31 | $0 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2018-12-31 | $0 |
| Total income from all sources (including contributions) | 2018-12-31 | $568,032 |
| Total loss/gain on sale of assets | 2018-12-31 | $0 |
| Total of all expenses incurred | 2018-12-31 | $92,696 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2018-12-31 | $92,696 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2018-12-31 | $568,032 |
| Value of total assets at end of year | 2018-12-31 | $475,336 |
| Value of total assets at beginning of year | 2018-12-31 | $0 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2018-12-31 | $0 |
| Total interest from all sources | 2018-12-31 | $0 |
| Total dividends received (eg from common stock, registered investment company shares) | 2018-12-31 | $0 |
| Was this plan covered by a fidelity bond | 2018-12-31 | No |
| Total non interest bearing cash at end of year | 2018-12-31 | $475,336 |
| Total non interest bearing cash at beginning of year | 2018-12-31 | $0 |
| Value of net income/loss | 2018-12-31 | $475,336 |
| Value of net assets at end of year (total assets less liabilities) | 2018-12-31 | $475,336 |
| Value of net assets at beginning of year (total assets less liabilities) | 2018-12-31 | $0 |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2018-12-31 | No |
| Contributions received in cash from employer | 2018-12-31 | $568,032 |
| Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers | 2018-12-31 | $92,696 |
| Total unrealized appreciation/depreciation of assets | 2018-07-31 | $0 |
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2018-07-31 | $0 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2018-07-31 | $0 |
| Total income from all sources (including contributions) | 2018-07-31 | $450,250 |
| Total loss/gain on sale of assets | 2018-07-31 | $0 |
| Total of all expenses incurred | 2018-07-31 | $159,142 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2018-07-31 | $159,142 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2018-07-31 | $450,250 |
| Value of total assets at end of year | 2018-07-31 | $291,108 |
| Value of total assets at beginning of year | 2018-07-31 | $0 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2018-07-31 | $0 |
| Total interest from all sources | 2018-07-31 | $0 |
| Total dividends received (eg from common stock, registered investment company shares) | 2018-07-31 | $0 |
| Was this plan covered by a fidelity bond | 2018-07-31 | No |
| Contributions received from participants | 2018-07-31 | $450,250 |
| Total non interest bearing cash at end of year | 2018-07-31 | $291,108 |
| Value of net income/loss | 2018-07-31 | $291,108 |
| Value of net assets at end of year (total assets less liabilities) | 2018-07-31 | $291,108 |
| Value of net assets at beginning of year (total assets less liabilities) | 2018-07-31 | $0 |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2018-07-31 | No |
| Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers | 2018-07-31 | $159,142 |
| 2022: PRIME GROUP HOLDINGS HEALTH BENEFIT 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 benefit arrangement – Insurance | Yes |
| 2021: PRIME GROUP HOLDINGS HEALTH BENEFIT 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 benefit arrangement – Insurance | Yes |
| 2020: PRIME GROUP HOLDINGS HEALTH BENEFIT 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 benefit arrangement – Insurance | Yes |
| 2019: PRIME GROUP HOLDINGS HEALTH BENEFIT PLAN 2019 form 5500 responses |
|---|
| 2019-01-01 | Type of plan entity | Single employer plan |
| 2019-01-01 | Submission has been amended | No |
| 2019-01-01 | This submission is the final filing | No |
| 2019-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2019-01-01 | Plan is a collectively bargained plan | No |
| 2019-01-01 | Plan funding arrangement – Insurance | Yes |
| 2019-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2018: PRIME GROUP HOLDINGS HEALTH BENEFIT PLAN 2018 form 5500 responses |
|---|
| 2018-08-01 | Type of plan entity | Single employer plan |
| 2018-08-01 | Submission has been amended | No |
| 2018-08-01 | This submission is the final filing | No |
| 2018-08-01 | This return/report is a short plan year return/report (less than 12 months) | Yes |
| 2018-08-01 | Plan is a collectively bargained plan | No |
| 2018-08-01 | Plan funding arrangement – Insurance | Yes |
| 2018-08-01 | Plan benefit arrangement – Insurance | Yes |
| 2017: PRIME GROUP HOLDINGS HEALTH BENEFIT PLAN 2017 form 5500 responses |
|---|
| 2017-08-01 | Type of plan entity | Single employer plan |
| 2017-08-01 | First time form 5500 has been submitted | Yes |
| 2017-08-01 | Submission has been amended | No |
| 2017-08-01 | This submission is the final filing | No |
| 2017-08-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2017-08-01 | Plan is a collectively bargained plan | No |
| 2017-08-01 | Plan funding arrangement – Insurance | Yes |
| 2017-08-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2017-08-01 | Plan benefit arrangement – Insurance | Yes |
| 2017-08-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| ANTHEM LIFE & DISABILITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 13573 ) |
| Policy contract number | 300201 |
| Policy instance | 2 |
| Insurance contract or identification number | 300201 | | Number of Individuals Covered | 509 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $22,312 | | Total amount of fees paid to insurance company | USD $2,116 | | Are there contracts with allocated funds for individual policies? | 0 | | 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 | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $140,932 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $22,312 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 2116 | | Additional information about fees paid to insurance broker | FEES |
|
| EMPIRE HEALTHCHOICE ASSURANCE, INC. (National Association of Insurance Commissioners NAIC id number: 55093 ) |
| Policy contract number | 300201 |
| Policy instance | 1 |
| Insurance contract or identification number | 300201 | | Number of Individuals Covered | 508 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $118,054 | | Total amount of fees paid to insurance company | USD $9,534 | | Are there contracts with allocated funds for individual policies? | 0 | | 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 | | Welfare Benefit Premiums Paid to Carrier | USD $2,916,769 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $118,054 | | Amount paid for insurance broker fees | 6864 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker organization code? | 3 |
|
| ANTHEM LIFE & DISABILITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 13573 ) |
| Policy contract number | 300201 |
| Policy instance | 2 |
| Insurance contract or identification number | 300201 | | Number of Individuals Covered | 474 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $11,425 | | Total amount of fees paid to insurance company | USD $970 | | Are there contracts with allocated funds for individual policies? | 0 | | 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 | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $100,490 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 970 | | Additional information about fees paid to insurance broker | BONUS, OVERRIDE, AND NON-MONETARY COMPENSATION | | Insurance broker organization code? | 3 | | Commission paid to Insurance Broker | USD $11,425 |
|
| EMPIRE HEALTHCHOICE ASSURANCE, INC. (National Association of Insurance Commissioners NAIC id number: 55093 ) |
| Policy contract number | 300201 |
| Policy instance | 1 |
| Insurance contract or identification number | 300201 | | Number of Individuals Covered | 495 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $121,155 | | Total amount of fees paid to insurance company | USD $1,557 | | Are there contracts with allocated funds for individual policies? | 0 | | 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 | | Welfare Benefit Premiums Paid to Carrier | USD $2,986,265 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 1557 | | Additional information about fees paid to insurance broker | BONUS, OVERRIDE, AND NON-MONETARY COMPENSATION | | Insurance broker organization code? | 3 | | Commission paid to Insurance Broker | USD $121,155 |
|
| ANTHEM LIFE & DISABILITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 13573 ) |
| Policy contract number | 300201 |
| Policy instance | 2 |
| Insurance contract or identification number | 300201 | | Number of Individuals Covered | 507 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $13,637 | | Total amount of fees paid to insurance company | USD $1,091 | | Are there contracts with allocated funds for individual policies? | 0 | | 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 | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $101,335 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $13,637 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 1091 | | Additional information about fees paid to insurance broker | BONUS, OVERRIDE, AND NON MONETARY COMPENSATION |
|
| EMPIRE HEALTHCHOICE ASSURANCE, INC. (National Association of Insurance Commissioners NAIC id number: 55093 ) |
| Policy contract number | 300201 |
| Policy instance | 1 |
| Insurance contract or identification number | 300201 | | Number of Individuals Covered | 307 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $114,148 | | Total amount of fees paid to insurance company | USD $1,938 | | Are there contracts with allocated funds for individual policies? | 0 | | 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 | | Welfare Benefit Premiums Paid to Carrier | USD $2,759,753 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 1938 | | Additional information about fees paid to insurance broker | BONUS, OVERRIDE, AND NON MONETARY COMPENSATION | | Insurance broker organization code? | 3 | | Commission paid to Insurance Broker | USD $114,148 |
|
| EMPIRE HEALTHCHOICE ASSURANCE, INC. (National Association of Insurance Commissioners NAIC id number: 55093 ) |
| Policy contract number | 300201 |
| Policy instance | 2 |
| Insurance contract or identification number | 300201 | | Number of Individuals Covered | 445 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $107,898 | | Total amount of fees paid to insurance company | USD $26,794 | | Are there contracts with allocated funds for individual policies? | 0 | | 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 | | Welfare Benefit Premiums Paid to Carrier | USD $2,323,865 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 3694 | | Additional information about fees paid to insurance broker | BONUS, OVERRIDE, AND NON MONETARY COMPENSATION | | Insurance broker organization code? | 3 | | Commission paid to Insurance Broker | USD $107,898 |
|
| ANTHEM LIFE & DISABILITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 13573 ) |
| Policy contract number | 300201 |
| Policy instance | 1 |
| Insurance contract or identification number | 300201 | | Number of Individuals Covered | 471 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $8,415 | | Are there contracts with allocated funds for individual policies? | 0 | | 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 | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $65,331 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,415 | | Insurance broker organization code? | 3 |
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| ANTHEM HEALTH PLANS, INC. (National Association of Insurance Commissioners NAIC id number: 60217 ) |
| Policy contract number | 300201 |
| Policy instance | 1 |
| Insurance contract or identification number | 300201 | | Number of Individuals Covered | 335 | | Insurance policy start date | 2018-08-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $28,320 | | Total amount of fees paid to insurance company | USD $6,160 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $683,008 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $28,320 | | Amount paid for insurance broker fees | 6160 | | Additional information about fees paid to insurance broker | BONUS, OVERRIDE, & NON MONETARY COMPENSATION | | Insurance broker organization code? | 3 |
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| HEALTHNOW NEW YORK, INC. DBA BLUESHIELD OF NORTHEASTERN NEW YORK (National Association of Insurance Commissioners NAIC id number: ) |
| Policy contract number | 00971047 |
| Policy instance | 1 |
| Insurance contract or identification number | 00971047 | | Number of Individuals Covered | 287 | | Insurance policy start date | 2017-08-01 | | Insurance policy end date | 2018-07-31 | | Total amount of commissions paid to insurance broker | USD $47,576 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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