ACIETA, LLC has sponsored the creation of one or more 401k plans.
Measure | Date | Value |
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2022: ACIETA, LLC HEALTH PLAN 2022 401k membership |
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Total participants, beginning-of-year | 2022-01-01 | 104 |
Total number of active participants reported on line 7a of the Form 5500 | 2022-01-01 | 108 |
Number of retired or separated participants receiving benefits | 2022-01-01 | 1 |
Number of other retired or separated participants entitled to future benefits | 2022-01-01 | 0 |
Total of all active and inactive participants | 2022-01-01 | 109 |
2021: ACIETA, LLC HEALTH PLAN 2021 401k membership |
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Total participants, beginning-of-year | 2021-01-01 | 108 |
Total number of active participants reported on line 7a of the Form 5500 | 2021-01-01 | 93 |
Number of retired or separated participants receiving benefits | 2021-01-01 | 1 |
Number of other retired or separated participants entitled to future benefits | 2021-01-01 | 0 |
Total of all active and inactive participants | 2021-01-01 | 94 |
2020: ACIETA, LLC HEALTH PLAN 2020 401k membership |
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Total participants, beginning-of-year | 2020-01-01 | 136 |
Total number of active participants reported on line 7a of the Form 5500 | 2020-01-01 | 109 |
Number of retired or separated participants receiving benefits | 2020-01-01 | 5 |
Total of all active and inactive participants | 2020-01-01 | 114 |
Total participants | 2020-01-01 | 114 |
2019: ACIETA, LLC HEALTH PLAN 2019 401k membership |
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Total participants, beginning-of-year | 2019-01-01 | 141 |
Total number of active participants reported on line 7a of the Form 5500 | 2019-01-01 | 135 |
Total of all active and inactive participants | 2019-01-01 | 135 |
2018: ACIETA, LLC HEALTH PLAN 2018 401k membership |
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Total participants, beginning-of-year | 2018-08-01 | 129 |
Total number of active participants reported on line 7a of the Form 5500 | 2018-08-01 | 141 |
Total of all active and inactive participants | 2018-08-01 | 141 |
2017: ACIETA, LLC HEALTH PLAN 2017 401k membership |
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Total participants, beginning-of-year | 2017-08-01 | 111 |
Total number of active participants reported on line 7a of the Form 5500 | 2017-08-01 | 126 |
Number of retired or separated participants receiving benefits | 2017-08-01 | 3 |
Total of all active and inactive participants | 2017-08-01 | 129 |
2016: ACIETA, LLC HEALTH PLAN 2016 401k membership |
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Total participants, beginning-of-year | 2016-08-01 | 127 |
Total number of active participants reported on line 7a of the Form 5500 | 2016-08-01 | 120 |
Number of retired or separated participants receiving benefits | 2016-08-01 | 5 |
Total of all active and inactive participants | 2016-08-01 | 125 |
2015: ACIETA, LLC HEALTH PLAN 2015 401k membership |
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Total participants, beginning-of-year | 2015-08-01 | 124 |
Total number of active participants reported on line 7a of the Form 5500 | 2015-08-01 | 126 |
Number of retired or separated participants receiving benefits | 2015-08-01 | 2 |
Number of other retired or separated participants entitled to future benefits | 2015-08-01 | 0 |
Total of all active and inactive participants | 2015-08-01 | 128 |
2022: ACIETA, LLC HEALTH PLAN 2022 form 5500 responses |
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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: ACIETA, LLC HEALTH PLAN 2021 form 5500 responses |
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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: ACIETA, LLC HEALTH PLAN 2020 form 5500 responses |
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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: ACIETA, LLC HEALTH PLAN 2019 form 5500 responses |
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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: ACIETA, LLC HEALTH PLAN 2018 form 5500 responses |
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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: ACIETA, LLC HEALTH PLAN 2017 form 5500 responses |
---|
2017-08-01 | Type of plan entity | Single employer plan |
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 benefit arrangement – Insurance | Yes |
2016: ACIETA, LLC HEALTH PLAN 2016 form 5500 responses |
---|
2016-08-01 | Type of plan entity | Single employer plan |
2016-08-01 | Submission has been amended | No |
2016-08-01 | This submission is the final filing | No |
2016-08-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2016-08-01 | Plan is a collectively bargained plan | No |
2016-08-01 | Plan funding arrangement – Insurance | Yes |
2016-08-01 | Plan benefit arrangement – Insurance | Yes |
2015: ACIETA, LLC HEALTH PLAN 2015 form 5500 responses |
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2015-08-01 | Type of plan entity | Single employer plan |
2015-08-01 | First time form 5500 has been submitted | Yes |
2015-08-01 | Submission has been amended | No |
2015-08-01 | This submission is the final filing | No |
2015-08-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2015-08-01 | Plan is a collectively bargained plan | No |
2015-08-01 | Plan funding arrangement – Insurance | Yes |
2015-08-01 | Plan benefit arrangement – Insurance | Yes |
WYSSTA INSURANCE COMPANY INC. (National Association of Insurance Commissioners NAIC id number: 12352 ) |
Policy contract number | 42567 |
Policy instance | 6 |
Insurance contract or identification number | 42567 | Number of Individuals Covered | 75 | Insurance policy start date | 2022-01-01 | Insurance policy end date | 2022-12-31 | Total amount of commissions paid to insurance broker | USD $743 | Total amount of fees paid to insurance company | USD $0 | 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 | 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 $9,282 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $743 | Insurance broker organization code? | 3 |
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UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
Policy contract number | R0748913 |
Policy instance | 5 |
Insurance contract or identification number | R0748913 | Number of Individuals Covered | 43 | Insurance policy start date | 2022-01-01 | Insurance policy end date | 2022-12-31 | Total amount of commissions paid to insurance broker | USD $196 | Total amount of fees paid to insurance company | USD $2 | 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 | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | ACCIDENT, CRITICAL ILLNESS | 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 $1,700 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $93 | Insurance broker organization code? | 3 | Amount paid for insurance broker fees | 2 | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION PAID |
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MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
Policy contract number | G000BNQS |
Policy instance | 4 |
Insurance contract or identification number | G000BNQS | Number of Individuals Covered | 106 | Insurance policy start date | 2022-01-01 | Insurance policy end date | 2022-12-31 | Total amount of commissions paid to insurance broker | USD $8,588 | Total amount of fees paid to insurance company | USD $212 | 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 | No | Long Term Disability Insurance Welfare Benefit | Yes | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT, VOL. LIFE/AD&D, ACCIDENT, CRITICAL ILLNESS | 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 $68,638 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $8,588 | Amount paid for insurance broker fees | 212 | Additional information about fees paid to insurance broker | OTHER COMPENSATION | Insurance broker organization code? | 3 |
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DELTA DENTAL OF WISCONSIN (National Association of Insurance Commissioners NAIC id number: 54046 ) |
Policy contract number | 10618 |
Policy instance | 3 |
Insurance contract or identification number | 10618 | Number of Individuals Covered | 57 | Insurance policy start date | 2022-01-01 | Insurance policy end date | 2022-12-31 | Total amount of commissions paid to insurance broker | USD $4,832 | Total amount of fees paid to insurance company | USD $0 | 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 | Yes | 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 $4,832 | Insurance broker organization code? | 3 |
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COMPCARE HEALTH SERVICES INSURANCE CORPORATION (National Association of Insurance Commissioners NAIC id number: 95693 ) |
Policy contract number | L01452 |
Policy instance | 2 |
Insurance contract or identification number | L01452 | Number of Individuals Covered | 40 | Insurance policy start date | 2022-01-01 | Insurance policy end date | 2022-12-31 | Total amount of commissions paid to insurance broker | USD $0 | Total amount of fees paid to insurance company | USD $0 | 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 $283,891 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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BLUE CROSS BLUE SHIELD OF WISCONSIN (National Association of Insurance Commissioners NAIC id number: 54003 ) |
Policy contract number | L01452 |
Policy instance | 1 |
Insurance contract or identification number | L01452 | Number of Individuals Covered | 170 | Insurance policy start date | 2022-01-01 | Insurance policy end date | 2022-12-31 | Total amount of commissions paid to insurance broker | USD $28,475 | Total amount of fees paid to insurance company | USD $0 | 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 | 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 $1,088,591 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $26,300 | Insurance broker organization code? | 3 |
|
COMPCARE HEALTH SERVICES INSURANCE CORPORATION (National Association of Insurance Commissioners NAIC id number: 95693 ) |
Policy contract number | L01452 |
Policy instance | 2 |
Insurance contract or identification number | L01452 | Number of Individuals Covered | 36 | Insurance policy start date | 2021-01-01 | Insurance policy end date | 2021-12-31 | Total amount of commissions paid to insurance broker | USD $0 | Total amount of fees paid to insurance company | USD $0 | 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 $230,582 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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DELTA DENTAL OF WISCONSIN (National Association of Insurance Commissioners NAIC id number: 54046 ) |
Policy contract number | 10618 |
Policy instance | 3 |
Insurance contract or identification number | 10618 | Number of Individuals Covered | 41 | Insurance policy start date | 2021-01-01 | Insurance policy end date | 2021-12-31 | Total amount of commissions paid to insurance broker | USD $4,517 | Total amount of fees paid to insurance company | USD $0 | 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 | Yes | 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 $4,517 | Insurance broker organization code? | 3 |
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MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
Policy contract number | G000BNQS |
Policy instance | 4 |
Insurance contract or identification number | G000BNQS | Number of Individuals Covered | 102 | Insurance policy start date | 2021-01-01 | Insurance policy end date | 2021-12-31 | Total amount of commissions paid to insurance broker | USD $4,981 | Total amount of fees paid to insurance company | USD $2,049 | 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 | No | Long Term Disability Insurance Welfare Benefit | Yes | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $46,435 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $2,898 | Amount paid for insurance broker fees | 2049 | Additional information about fees paid to insurance broker | OTHER COMPENSATION | Insurance broker organization code? | 3 |
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UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
Policy contract number | R0748913 |
Policy instance | 5 |
Insurance contract or identification number | R0748913 | Number of Individuals Covered | 48 | Insurance policy start date | 2021-01-01 | Insurance policy end date | 2021-12-31 | Total amount of commissions paid to insurance broker | USD $1,118 | Total amount of fees paid to insurance company | USD $12 | 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 | No | Temporary Disability Insurance Welfare Benefit | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | ACCIDENT, CRITICAL ILLNESS | 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 $10,306 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $523 | Amount paid for insurance broker fees | 12 | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION PAID | Insurance broker organization code? | 3 |
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WYSSTA INSURANCE COMPANY INC. (National Association of Insurance Commissioners NAIC id number: 12352 ) |
Policy contract number | 42567 |
Policy instance | 6 |
Insurance contract or identification number | 42567 | Number of Individuals Covered | 68 | Insurance policy start date | 2021-01-01 | Insurance policy end date | 2021-12-31 | Total amount of commissions paid to insurance broker | USD $731 | Total amount of fees paid to insurance company | USD $0 | 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 | 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 $9,135 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $731 | Insurance broker organization code? | 3 |
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BLUE CROSS BLUE SHIELD OF WISCONSIN (National Association of Insurance Commissioners NAIC id number: 54003 ) |
Policy contract number | L01452 |
Policy instance | 1 |
Insurance contract or identification number | L01452 | Number of Individuals Covered | 173 | Insurance policy start date | 2021-01-01 | Insurance policy end date | 2021-12-31 | Total amount of commissions paid to insurance broker | USD $20,550 | Total amount of fees paid to insurance company | USD $4,132 | 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 $986,092 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $14,325 | Amount paid for insurance broker fees | 4132 | Additional information about fees paid to insurance broker | FEES PAID | Insurance broker organization code? | 3 |
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UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
Policy contract number | 908727 |
Policy instance | 1 |
Insurance contract or identification number | 908727 | Number of Individuals Covered | 253 | Insurance policy start date | 2020-01-01 | Insurance policy end date | 2020-12-31 | Total amount of commissions paid to insurance broker | USD $0 | Total amount of fees paid to insurance company | USD $54,943 | 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 $1,569,110 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Amount paid for insurance broker fees | 54943 | Additional information about fees paid to insurance broker | SERVICE FEE AGREEMENT AND BONUS | Insurance broker organization code? | 3 |
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DELTA DENTAL OF WISCONSIN (National Association of Insurance Commissioners NAIC id number: 54046 ) |
Policy contract number | 10618 |
Policy instance | 3 |
Insurance contract or identification number | 10618 | Number of Individuals Covered | 53 | Insurance policy start date | 2020-01-01 | Insurance policy end date | 2020-12-31 | Total amount of commissions paid to insurance broker | USD $2,495 | Total amount of fees paid to insurance company | USD $0 | 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 | Yes | 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 $2,495 | Insurance broker organization code? | 3 |
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MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
Policy contract number | GLTD0BNQS |
Policy instance | 4 |
Insurance contract or identification number | GLTD0BNQS | Number of Individuals Covered | 93 | Insurance policy start date | 2020-01-01 | Insurance policy end date | 2020-12-31 | 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 | No | Temporary Disability Insurance Welfare Benefit | No | 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 $14,783 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
Policy contract number | GLUG0BNQS |
Policy instance | 5 |
Insurance contract or identification number | GLUG0BNQS | Number of Individuals Covered | 109 | Insurance policy start date | 2020-01-01 | Insurance policy end date | 2020-12-31 | Total amount of commissions paid to insurance broker | USD $733 | Total amount of fees paid to insurance company | USD $0 | 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 | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | AD&D | 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 $7,333 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $733 | Insurance broker organization code? | 3 |
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MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
Policy contract number | GVTL0BNQS |
Policy instance | 6 |
Insurance contract or identification number | GVTL0BNQS | Number of Individuals Covered | 61 | Insurance policy start date | 2020-01-01 | Insurance policy end date | 2020-12-31 | Total amount of commissions paid to insurance broker | USD $4,579 | 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 | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | AD&D | 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 $30,528 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $4,579 | Insurance broker organization code? | 3 |
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DELTA DENTAL OF WISCONSIN (National Association of Insurance Commissioners NAIC id number: 54046 ) |
Policy contract number | 10518 |
Policy instance | 2 |
Insurance contract or identification number | 10518 | Number of Individuals Covered | 31 | Insurance policy start date | 2020-01-01 | Insurance policy end date | 2020-12-31 | Total amount of commissions paid to insurance broker | USD $1,840 | Total amount of fees paid to insurance company | USD $0 | 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 | Yes | 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 $1,840 | Insurance broker organization code? | 3 |
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UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
Policy contract number | 908727 |
Policy instance | 5 |
Insurance contract or identification number | 908727 | Number of Individuals Covered | 303 | Insurance policy start date | 2019-01-01 | Insurance policy end date | 2019-12-31 | Total amount of commissions paid to insurance broker | USD $0 | Total amount of fees paid to insurance company | USD $52,190 | Health Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $1,689,012 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Amount paid for insurance broker fees | 52190 | Additional information about fees paid to insurance broker | SERVICE FEE AGREEMENT | Insurance broker organization code? | 3 |
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DELTA DENTAL OF WISCONSIN (National Association of Insurance Commissioners NAIC id number: 54046 ) |
Policy contract number | 10518 |
Policy instance | 4 |
Insurance contract or identification number | 10518 | Insurance policy start date | 2019-01-01 | Insurance policy end date | 2019-12-31 | Total amount of commissions paid to insurance broker | USD $1,811 | Total amount of fees paid to insurance company | USD $0 | Dental 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 $1,811 | Insurance broker organization code? | 3 |
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LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
Policy contract number | SLI600182 |
Policy instance | 3 |
Insurance contract or identification number | SLI600182 | Number of Individuals Covered | 135 | Insurance policy start date | 2019-01-02 | Insurance policy end date | 2019-12-31 | Total amount of commissions paid to insurance broker | USD $3,660 | Total amount of fees paid to insurance company | USD $0 | Life Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $36,595 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $3,660 | Insurance broker organization code? | 3 |
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LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
Policy contract number | SOK604750 |
Policy instance | 2 |
Insurance contract or identification number | SOK604750 | Number of Individuals Covered | 135 | Insurance policy start date | 2019-01-01 | Insurance policy end date | 2019-12-31 | Total amount of commissions paid to insurance broker | USD $739 | Total amount of fees paid to insurance company | USD $0 | Other welfare benefits provided | AD&D | Welfare Benefit Premiums Paid to Carrier | USD $7,392 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $739 | Insurance broker organization code? | 3 |
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LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
Policy contract number | SGD606946 |
Policy instance | 1 |
Insurance contract or identification number | SGD606946 | Number of Individuals Covered | 108 | Insurance policy start date | 2019-01-01 | Insurance policy end date | 2019-12-31 | Total amount of commissions paid to insurance broker | USD $1,740 | Total amount of fees paid to insurance company | USD $0 | Long Term Disability Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $17,403 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $1,740 | Insurance broker organization code? | 3 |
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LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
Policy contract number | SOK604750 |
Policy instance | 5 |
Insurance contract or identification number | SOK604750 | Insurance policy start date | 2018-08-01 | Insurance policy end date | 2018-12-31 | Total amount of commissions paid to insurance broker | USD $0 | Total amount of fees paid to insurance company | USD $0 | Other welfare benefits provided | AD&D | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | Insurance broker organization code? | 3 |
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LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
Policy contract number | SLI600182 |
Policy instance | 4 |
Insurance contract or identification number | SLI600182 | Number of Individuals Covered | 141 | Insurance policy start date | 2018-08-01 | Insurance policy end date | 2018-12-31 | Total amount of commissions paid to insurance broker | USD $2,018 | Total amount of fees paid to insurance company | USD $0 | Life Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $20,177 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $2,018 | Insurance broker organization code? | 3 |
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UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
Policy contract number | 908727 |
Policy instance | 2 |
Insurance contract or identification number | 908727 | Number of Individuals Covered | 119 | Insurance policy start date | 2018-08-01 | Insurance policy end date | 2018-12-31 | Total amount of commissions paid to insurance broker | USD $3 | Total amount of fees paid to insurance company | USD $21,704 | Health Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $702,430 | 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 | Amount paid for insurance broker fees | 21704 | Additional information about fees paid to insurance broker | SERVICE FEE AGREEMENT | Insurance broker organization code? | 3 |
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CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
Policy contract number | 00613988 |
Policy instance | 3 |
Insurance contract or identification number | 00613988 | Number of Individuals Covered | 96 | Insurance policy start date | 2018-08-01 | Insurance policy end date | 2018-12-31 | Total amount of commissions paid to insurance broker | USD $233 | Total amount of fees paid to insurance company | USD $0 | Dental Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $4,669 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $233 | Insurance broker organization code? | 3 |
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LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
Policy contract number | SGD606946 |
Policy instance | 1 |
Insurance contract or identification number | SGD606946 | Insurance policy start date | 2018-08-01 | Insurance policy end date | 2018-12-31 | Total amount of commissions paid to insurance broker | USD $0 | Total amount of fees paid to insurance company | USD $0 | Long Term Disability Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $0 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
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LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
Policy contract number | SLI600182 |
Policy instance | 1 |
Insurance contract or identification number | SLI600182 | Number of Individuals Covered | 129 | Insurance policy start date | 2017-08-01 | Insurance policy end date | 2018-07-31 | Total amount of commissions paid to insurance broker | USD $1,661 | Life Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $16,608 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
Policy contract number | SGD606946 |
Policy instance | 2 |
Insurance contract or identification number | SGD606946 | Number of Individuals Covered | 98 | Insurance policy start date | 2017-08-01 | Insurance policy end date | 2018-07-31 | Total amount of commissions paid to insurance broker | USD $944 | Total amount of fees paid to insurance company | USD $0 | Long Term Disability Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $9,436 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
Policy contract number | SOK604750 |
Policy instance | 3 |
Insurance contract or identification number | SOK604750 | Number of Individuals Covered | 129 | Insurance policy start date | 2017-08-01 | Insurance policy end date | 2018-07-31 | Total amount of commissions paid to insurance broker | USD $308 | Other welfare benefits provided | AD&D | Welfare Benefit Premiums Paid to Carrier | USD $3,084 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
Policy contract number | 00613988 |
Policy instance | 4 |
Insurance contract or identification number | 00613988 | Number of Individuals Covered | 158 | Insurance policy start date | 2017-08-01 | Insurance policy end date | 2018-07-31 | Total amount of commissions paid to insurance broker | USD $2,766 | Total amount of fees paid to insurance company | USD $0 | Dental Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $55,328 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
Policy contract number | 908727 |
Policy instance | 5 |
Insurance contract or identification number | 908727 | Number of Individuals Covered | 294 | Insurance policy start date | 2017-08-01 | Insurance policy end date | 2018-07-31 | Total amount of commissions paid to insurance broker | USD $1,389 | Total amount of fees paid to insurance company | USD $51,759 | Health Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $1,510,136 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
Policy contract number | SLI600182 |
Policy instance | 6 |
Insurance contract or identification number | SLI600182 | Number of Individuals Covered | 126 | Insurance policy start date | 2015-08-01 | Insurance policy end date | 2016-07-31 | Total amount of commissions paid to insurance broker | USD $2,454 | Total amount of fees paid to insurance company | USD $1,156 | Life Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $24,640 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $2,454 | Amount paid for insurance broker fees | 1156 | Additional information about fees paid to insurance broker | OVERRIDE | Insurance broker organization code? | 3 | Insurance broker name | M3 INSURANCE |
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LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
Policy contract number | SOK604750 |
Policy instance | 5 |
Insurance contract or identification number | SOK604750 | Number of Individuals Covered | 126 | Insurance policy start date | 2015-08-01 | Insurance policy end date | 2016-07-31 | Total amount of commissions paid to insurance broker | USD $412 | Total amount of fees paid to insurance company | USD $204 | Other welfare benefits provided | AD&D | Welfare Benefit Premiums Paid to Carrier | USD $4,117 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $412 | Amount paid for insurance broker fees | 204 | Additional information about fees paid to insurance broker | OVERRIDE | Insurance broker organization code? | 3 | Insurance broker name | M3 INSURANCE |
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LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
Policy contract number | SGD606946 |
Policy instance | 4 |
Insurance contract or identification number | SGD606946 | Number of Individuals Covered | 96 | Insurance policy start date | 2015-08-01 | Insurance policy end date | 2016-07-31 | Total amount of commissions paid to insurance broker | USD $1,258 | Total amount of fees paid to insurance company | USD $597 | Long Term Disability Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $12,585 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $1,258 | Amount paid for insurance broker fees | 597 | Additional information about fees paid to insurance broker | OVERRIDE | Insurance broker organization code? | 3 | Insurance broker name | M3 INSURANCE |
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UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 ) |
Policy contract number | 5477277 |
Policy instance | 3 |
Insurance contract or identification number | 5477277 | Number of Individuals Covered | 68 | Insurance policy start date | 2015-08-01 | Insurance policy end date | 2016-07-31 | Total amount of commissions paid to insurance broker | USD $1,769 | Total amount of fees paid to insurance company | USD $278 | Vision Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $12,690 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $1,769 | Amount paid for insurance broker fees | 278 | Additional information about fees paid to insurance broker | OVERRIDE | Insurance broker organization code? | 3 | Insurance broker name | M3 INSURANCE |
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CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
Policy contract number | 00613988 |
Policy instance | 2 |
Insurance contract or identification number | 00613988 | Number of Individuals Covered | 102 | Insurance policy start date | 2015-08-01 | Insurance policy end date | 2016-07-31 | Health Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $1,225,112 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
Policy contract number | 00613988 |
Policy instance | 1 |
Insurance contract or identification number | 00613988 | Number of Individuals Covered | 84 | Insurance policy start date | 2015-08-01 | Insurance policy end date | 2016-07-31 | Total amount of commissions paid to insurance broker | USD $2,453 | Total amount of fees paid to insurance company | USD $0 | Dental Insurance Welfare Benefit | Yes | Welfare Benefit Premiums Paid to Carrier | USD $49,058 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $2,453 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 | Insurance broker name | M3 INSURANCE |
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