FRANCISCAN CARE SERVICES, INC. has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan FRANCISCAN CARE SERVICES, INC. EMPLOYEE BENEFITS PLAN
401k plan membership statisitcs for FRANCISCAN CARE SERVICES, INC. EMPLOYEE BENEFITS PLAN
| Measure | Date | Value |
|---|
| 2023: FRANCISCAN CARE SERVICES, INC. EMPLOYEE BENEFITS PLAN 2023 401k membership |
|---|
| Total participants, beginning-of-year | 2023-01-01 | 209 |
| Total number of active participants reported on line 7a of the Form 5500 | 2023-01-01 | 226 |
| Number of retired or separated participants receiving benefits | 2023-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2023-01-01 | 0 |
| Total of all active and inactive participants | 2023-01-01 | 226 |
| Number of employers contributing to the scheme | 2023-01-01 | 0 |
| 2022: FRANCISCAN CARE SERVICES, INC. EMPLOYEE BENEFITS PLAN 2022 401k membership |
|---|
| Total participants, beginning-of-year | 2022-01-01 | 197 |
| Total number of active participants reported on line 7a of the Form 5500 | 2022-01-01 | 209 |
| Number of retired or separated participants receiving benefits | 2022-01-01 | 0 |
| 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 | 209 |
| Number of employers contributing to the scheme | 2022-01-01 | 0 |
| 2021: FRANCISCAN CARE SERVICES, INC. EMPLOYEE BENEFITS PLAN 2021 401k membership |
|---|
| Total participants, beginning-of-year | 2021-01-01 | 193 |
| Total number of active participants reported on line 7a of the Form 5500 | 2021-01-01 | 197 |
| Number of retired or separated participants receiving benefits | 2021-01-01 | 0 |
| 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 | 197 |
| Number of employers contributing to the scheme | 2021-01-01 | 0 |
| 2020: FRANCISCAN CARE SERVICES, INC. EMPLOYEE BENEFITS PLAN 2020 401k membership |
|---|
| Total participants, beginning-of-year | 2020-04-01 | 183 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-04-01 | 193 |
| Number of retired or separated participants receiving benefits | 2020-04-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2020-04-01 | 0 |
| Total of all active and inactive participants | 2020-04-01 | 193 |
| Number of employers contributing to the scheme | 2020-04-01 | 0 |
| 2019: FRANCISCAN CARE SERVICES, INC. EMPLOYEE BENEFITS PLAN 2019 401k membership |
|---|
| Total participants, beginning-of-year | 2019-04-01 | 193 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-04-01 | 183 |
| Number of retired or separated participants receiving benefits | 2019-04-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2019-04-01 | 0 |
| Total of all active and inactive participants | 2019-04-01 | 183 |
| Number of employers contributing to the scheme | 2019-04-01 | 0 |
| 2018: FRANCISCAN CARE SERVICES, INC. EMPLOYEE BENEFITS PLAN 2018 401k membership |
|---|
| Total participants, beginning-of-year | 2018-04-01 | 222 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-04-01 | 193 |
| Number of retired or separated participants receiving benefits | 2018-04-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2018-04-01 | 0 |
| Total of all active and inactive participants | 2018-04-01 | 193 |
| Number of employers contributing to the scheme | 2018-04-01 | 0 |
| 2017: FRANCISCAN CARE SERVICES, INC. EMPLOYEE BENEFITS PLAN 2017 401k membership |
|---|
| Total participants, beginning-of-year | 2017-04-01 | 235 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-04-01 | 222 |
| Number of retired or separated participants receiving benefits | 2017-04-01 | 2 |
| Number of other retired or separated participants entitled to future benefits | 2017-04-01 | 0 |
| Total of all active and inactive participants | 2017-04-01 | 224 |
| Number of employers contributing to the scheme | 2017-04-01 | 0 |
| 2016: FRANCISCAN CARE SERVICES, INC. EMPLOYEE BENEFITS PLAN 2016 401k membership |
|---|
| Total participants, beginning-of-year | 2016-04-01 | 233 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-04-01 | 234 |
| Number of retired or separated participants receiving benefits | 2016-04-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2016-04-01 | 0 |
| Total of all active and inactive participants | 2016-04-01 | 234 |
| 2015: FRANCISCAN CARE SERVICES, INC. EMPLOYEE BENEFITS PLAN 2015 401k membership |
|---|
| Total participants, beginning-of-year | 2015-04-01 | 222 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-04-01 | 231 |
| Number of retired or separated participants receiving benefits | 2015-04-01 | 2 |
| Number of other retired or separated participants entitled to future benefits | 2015-04-01 | 0 |
| Total of all active and inactive participants | 2015-04-01 | 233 |
| 2014: FRANCISCAN CARE SERVICES, INC. EMPLOYEE BENEFITS PLAN 2014 401k membership |
|---|
| Total participants, beginning-of-year | 2014-04-01 | 221 |
| Total number of active participants reported on line 7a of the Form 5500 | 2014-04-01 | 222 |
| Number of retired or separated participants receiving benefits | 2014-04-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2014-04-01 | 0 |
| Total of all active and inactive participants | 2014-04-01 | 222 |
| 2013: FRANCISCAN CARE SERVICES, INC. EMPLOYEE BENEFITS PLAN 2013 401k membership |
|---|
| Total participants, beginning-of-year | 2013-04-01 | 212 |
| Total number of active participants reported on line 7a of the Form 5500 | 2013-04-01 | 208 |
| Number of retired or separated participants receiving benefits | 2013-04-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2013-04-01 | 0 |
| Total of all active and inactive participants | 2013-04-01 | 208 |
| 2023: FRANCISCAN CARE SERVICES, INC. EMPLOYEE BENEFITS PLAN 2023 form 5500 responses |
|---|
| 2023-01-01 | Type of plan entity | Single employer plan |
| 2023-01-01 | Plan funding arrangement – Insurance | Yes |
| 2023-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2023-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2023-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2022: FRANCISCAN CARE SERVICES, INC. EMPLOYEE BENEFITS PLAN 2022 form 5500 responses |
|---|
| 2022-01-01 | Type of plan entity | Single employer plan |
| 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: FRANCISCAN CARE SERVICES, INC. EMPLOYEE BENEFITS PLAN 2021 form 5500 responses |
|---|
| 2021-01-01 | Type of plan entity | Single employer plan |
| 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: FRANCISCAN CARE SERVICES, INC. EMPLOYEE BENEFITS PLAN 2020 form 5500 responses |
|---|
| 2020-04-01 | Type of plan entity | Single employer plan |
| 2020-04-01 | This return/report is a short plan year return/report (less than 12 months) | Yes |
| 2020-04-01 | Plan funding arrangement – Insurance | Yes |
| 2020-04-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2020-04-01 | Plan benefit arrangement – Insurance | Yes |
| 2020-04-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2019: FRANCISCAN CARE SERVICES, INC. EMPLOYEE BENEFITS PLAN 2019 form 5500 responses |
|---|
| 2019-04-01 | Type of plan entity | Single employer plan |
| 2019-04-01 | Plan funding arrangement – Insurance | Yes |
| 2019-04-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2019-04-01 | Plan benefit arrangement – Insurance | Yes |
| 2019-04-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2018: FRANCISCAN CARE SERVICES, INC. EMPLOYEE BENEFITS PLAN 2018 form 5500 responses |
|---|
| 2018-04-01 | Type of plan entity | Single employer plan |
| 2018-04-01 | Plan funding arrangement – Insurance | Yes |
| 2018-04-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2018-04-01 | Plan benefit arrangement – Insurance | Yes |
| 2018-04-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2017: FRANCISCAN CARE SERVICES, INC. EMPLOYEE BENEFITS PLAN 2017 form 5500 responses |
|---|
| 2017-04-01 | Type of plan entity | Single employer plan |
| 2017-04-01 | Submission has been amended | No |
| 2017-04-01 | This submission is the final filing | No |
| 2017-04-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2017-04-01 | Plan is a collectively bargained plan | No |
| 2017-04-01 | Plan funding arrangement – Insurance | Yes |
| 2017-04-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2017-04-01 | Plan benefit arrangement – Insurance | Yes |
| 2017-04-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2016: FRANCISCAN CARE SERVICES, INC. EMPLOYEE BENEFITS PLAN 2016 form 5500 responses |
|---|
| 2016-04-01 | Type of plan entity | Single employer plan |
| 2016-04-01 | Submission has been amended | No |
| 2016-04-01 | This submission is the final filing | No |
| 2016-04-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2016-04-01 | Plan is a collectively bargained plan | No |
| 2016-04-01 | Plan funding arrangement – Insurance | Yes |
| 2016-04-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2016-04-01 | Plan benefit arrangement – Insurance | Yes |
| 2016-04-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2015: FRANCISCAN CARE SERVICES, INC. EMPLOYEE BENEFITS PLAN 2015 form 5500 responses |
|---|
| 2015-04-01 | Type of plan entity | Single employer plan |
| 2015-04-01 | Submission has been amended | No |
| 2015-04-01 | This submission is the final filing | No |
| 2015-04-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2015-04-01 | Plan is a collectively bargained plan | No |
| 2015-04-01 | Plan funding arrangement – Insurance | Yes |
| 2015-04-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2015-04-01 | Plan benefit arrangement – Insurance | Yes |
| 2015-04-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2014: FRANCISCAN CARE SERVICES, INC. EMPLOYEE BENEFITS PLAN 2014 form 5500 responses |
|---|
| 2014-04-01 | Type of plan entity | Single employer plan |
| 2014-04-01 | Submission has been amended | No |
| 2014-04-01 | This submission is the final filing | No |
| 2014-04-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2014-04-01 | Plan is a collectively bargained plan | No |
| 2014-04-01 | Plan funding arrangement – Insurance | Yes |
| 2014-04-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2014-04-01 | Plan benefit arrangement – Insurance | Yes |
| 2014-04-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2013: FRANCISCAN CARE SERVICES, INC. EMPLOYEE BENEFITS PLAN 2013 form 5500 responses |
|---|
| 2013-04-01 | Type of plan entity | Single employer plan |
| 2013-04-01 | First time form 5500 has been submitted | Yes |
| 2013-04-01 | Submission has been amended | No |
| 2013-04-01 | This submission is the final filing | No |
| 2013-04-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2013-04-01 | Plan is a collectively bargained plan | No |
| 2013-04-01 | Plan funding arrangement – Insurance | Yes |
| 2013-04-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2013-04-01 | Plan benefit arrangement – Insurance | Yes |
| 2013-04-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 ) |
| Policy contract number | 1149253 |
| Policy instance | 2 |
| Insurance contract or identification number | 1149253 | | Number of Individuals Covered | 570 | | Insurance policy start date | 2023-01-01 | | Insurance policy end date | 2023-12-31 | | Total amount of commissions paid to insurance broker | USD $7,236 | | Total amount of fees paid to insurance company | USD $1,414 | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $161,472 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
| Policy contract number | 892262G |
| Policy instance | 1 |
| Insurance contract or identification number | 892262G | | Number of Individuals Covered | 226 | | Insurance policy start date | 2023-01-01 | | Insurance policy end date | 2023-12-31 | | Total amount of commissions paid to insurance broker | USD $19,581 | | Total amount of fees paid to insurance company | USD $3,599 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT, ACCIDENT, CRITICAL ILLNESS, HOSPITAL | | Welfare Benefit Premiums Paid to Carrier | USD $181,622 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 ) |
| Policy contract number | 1149253 |
| Policy instance | 3 |
| Insurance contract or identification number | 1149253 | | Number of Individuals Covered | 537 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $7,145 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $157,730 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,145 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| CONTINENTAL AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71730 ) |
| Policy contract number | 21393 |
| Policy instance | 2 |
| Insurance contract or identification number | 21393 | | Number of Individuals Covered | 6 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $307 | | Total amount of fees paid to insurance company | USD $0 | | Temporary Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENT, CRITICAL ILLNESS, HOSPITAL | | Welfare Benefit Premiums Paid to Carrier | USD $5,156 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $146 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
| Policy contract number | 892262G |
| Policy instance | 1 |
| Insurance contract or identification number | 892262G | | Number of Individuals Covered | 209 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $16,490 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT, ACCIDENT, CRITICAL ILLNESS, HOSPITAL | | Welfare Benefit Premiums Paid to Carrier | USD $154,299 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $16,490 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 ) |
| Policy contract number | 647149 |
| Policy instance | 2 |
| Insurance contract or identification number | 647149 | | Number of Individuals Covered | 167 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $2,975 | | Total amount of fees paid to insurance company | USD $292 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $32,552 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,975 | | Amount paid for insurance broker fees | 292 | | Additional information about fees paid to insurance broker | CONTINGENT COMPENSATION | | Insurance broker organization code? | 3 |
|
| AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 ) |
| Policy contract number | 28750 |
| Policy instance | 3 |
| Insurance contract or identification number | 28750 | | Number of Individuals Covered | 21 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $198 | | Total amount of fees paid to insurance company | USD $5 | | Other welfare benefits provided | ACCIDENT | | Welfare Benefit Premiums Paid to Carrier | USD $1,611 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $164 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Additional information about fees paid to insurance broker | SUPPLEMENTAL COMPENSATION |
|
| CONTINENTAL AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71730 ) |
| Policy contract number | 21393 |
| Policy instance | 4 |
| Insurance contract or identification number | 21393 | | Number of Individuals Covered | 105 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $533 | | Total amount of fees paid to insurance company | USD $0 | | Temporary Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENT, CRITICAL ILLNESS, HOSPITAL | | Welfare Benefit Premiums Paid to Carrier | USD $10,155 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $279 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 ) |
| Policy contract number | 010-048077 |
| Policy instance | 5 |
| Insurance contract or identification number | 010-048077 | | Number of Individuals Covered | 433 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $12,843 | | Total amount of fees paid to insurance company | USD $1,783 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $128,428 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $12,843 | | Amount paid for insurance broker fees | 1783 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker organization code? | 3 |
|
| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
| Policy contract number | 892262G |
| Policy instance | 1 |
| Insurance contract or identification number | 892262G | | Number of Individuals Covered | 189 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $14,842 | | Total amount of fees paid to insurance company | USD $8,632 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT, ACCIDENT, CRITICAL ILLNESS, HOSPITAL | | Welfare Benefit Premiums Paid to Carrier | USD $138,313 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $14,842 | | Amount paid for insurance broker fees | 8632 | | Additional information about fees paid to insurance broker | BONUS | | Insurance broker organization code? | 3 |
|
| PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 ) |
| Policy contract number | 02081 |
| Policy instance | 1 |
| Insurance contract or identification number | 02081 | | Number of Individuals Covered | 191 | | Insurance policy start date | 2019-07-01 | | Insurance policy end date | 2020-06-30 | | Total amount of commissions paid to insurance broker | USD $13,540 | | Total amount of fees paid to insurance company | USD $54 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $140,609 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $13,540 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Additional information about fees paid to insurance broker | THIRD PARTY ADMINISTRATION FEES |
|
| STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 ) |
| Policy contract number | 647149 |
| Policy instance | 2 |
| Insurance contract or identification number | 647149 | | Number of Individuals Covered | 157 | | Insurance policy start date | 2019-07-01 | | Insurance policy end date | 2020-06-30 | | Total amount of commissions paid to insurance broker | USD $2,868 | | Total amount of fees paid to insurance company | USD $437 | | Vision 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? | No | | Commission paid to Insurance Broker | USD $1,569 | | Amount paid for insurance broker fees | 437 | | Additional information about fees paid to insurance broker | CONTINGENT COMPENSATION | | Insurance broker organization code? | 3 |
|
| AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 ) |
| Policy contract number | 28750 |
| Policy instance | 3 |
| Insurance contract or identification number | 28750 | | Number of Individuals Covered | 61 | | Insurance policy start date | 2019-08-01 | | Insurance policy end date | 2020-07-31 | | Total amount of commissions paid to insurance broker | USD $4,796 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | ACCIDENT | | Welfare Benefit Premiums Paid to Carrier | USD $18,718 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,796 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 ) |
| Policy contract number | 010-048077 |
| Policy instance | 4 |
| Insurance contract or identification number | 010-048077 | | Number of Individuals Covered | 374 | | Insurance policy start date | 2019-06-01 | | Insurance policy end date | 2020-05-31 | | Total amount of commissions paid to insurance broker | USD $11,352 | | Total amount of fees paid to insurance company | USD $699 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $113,520 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,597 | | Amount paid for insurance broker fees | 699 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker organization code? | 3 |
|
| PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 ) |
| Policy contract number | 02081 |
| Policy instance | 5 |
| Insurance contract or identification number | 02081 | | Number of Individuals Covered | 193 | | Insurance policy start date | 2020-07-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $8,363 | | Total amount of fees paid to insurance company | USD $25 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $74,367 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,363 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Additional information about fees paid to insurance broker | THIRD PARTY ADMINISTRATION FEES |
|
| STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 ) |
| Policy contract number | 647149 |
| Policy instance | 6 |
| Insurance contract or identification number | 647149 | | Number of Individuals Covered | 157 | | Insurance policy start date | 2020-07-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $1,804 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,804 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 ) |
| Policy contract number | 28750 |
| Policy instance | 7 |
| Insurance contract or identification number | 28750 | | Number of Individuals Covered | 63 | | Insurance policy start date | 2020-08-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $1,229 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | ACCIDENT | | Welfare Benefit Premiums Paid to Carrier | USD $8,183 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,179 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| CONTINENTAL AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71730 ) |
| Policy contract number | 21393 |
| Policy instance | 8 |
| Insurance contract or identification number | 21393 | | Number of Individuals Covered | 105 | | Insurance policy start date | 2020-03-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $3,404 | | Total amount of fees paid to insurance company | USD $0 | | Temporary Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENT, CRITICAL ILLNESS, HOSPITAL | | Welfare Benefit Premiums Paid to Carrier | USD $49,828 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,849 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 ) |
| Policy contract number | 010-048077 |
| Policy instance | 9 |
| Insurance contract or identification number | 010-048077 | | Number of Individuals Covered | 376 | | Insurance policy start date | 2020-06-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $6,701 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $67,008 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,701 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 ) |
| Policy contract number | 010-048077 |
| Policy instance | 5 |
| Insurance contract or identification number | 010-048077 | | Number of Individuals Covered | 371 | | Insurance policy start date | 2018-06-01 | | Insurance policy end date | 2019-05-31 | | Total amount of commissions paid to insurance broker | USD $12,077 | | Total amount of fees paid to insurance company | USD $2,959 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $120,769 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $12,077 | | Amount paid for insurance broker fees | 2959 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker organization code? | 3 |
|
| CONTINENTAL AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71730 ) |
| Policy contract number | 21393 |
| Policy instance | 4 |
| Insurance contract or identification number | 21393 | | Number of Individuals Covered | 105 | | Insurance policy start date | 2019-03-01 | | Insurance policy end date | 2020-02-28 | | Total amount of commissions paid to insurance broker | USD $7,291 | | Total amount of fees paid to insurance company | USD $0 | | Temporary Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENT, CRITICAL ILLNESS, HOSPITAL | | Welfare Benefit Premiums Paid to Carrier | USD $64,636 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,760 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 ) |
| Policy contract number | 28750 |
| Policy instance | 3 |
| Insurance contract or identification number | 28750 | | Number of Individuals Covered | 39 | | Insurance policy start date | 2018-08-01 | | Insurance policy end date | 2019-07-31 | | Total amount of commissions paid to insurance broker | USD $2,117 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | ACCIDENT | | Welfare Benefit Premiums Paid to Carrier | USD $13,667 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,117 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 ) |
| Policy contract number | 647149 |
| Policy instance | 2 |
| Insurance contract or identification number | 647149 | | Number of Individuals Covered | 148 | | Insurance policy start date | 2018-07-01 | | Insurance policy end date | 2019-06-30 | | Total amount of commissions paid to insurance broker | USD $3,193 | | Total amount of fees paid to insurance company | USD $314 | | Vision Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,193 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Additional information about fees paid to insurance broker | CONTINGENT COMPENSATION |
|
| PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 ) |
| Policy contract number | 02081 |
| Policy instance | 1 |
| Insurance contract or identification number | 02081 | | Number of Individuals Covered | 183 | | Insurance policy start date | 2018-07-01 | | Insurance policy end date | 2019-06-30 | | Total amount of commissions paid to insurance broker | USD $14,273 | | Total amount of fees paid to insurance company | USD $67 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $145,383 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $14,273 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Additional information about fees paid to insurance broker | THIRD PARTY ADMINISTRATION FEES |
|
| PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 ) |
| Policy contract number | 1064647 |
| Policy instance | 5 |
| Insurance contract or identification number | 1064647 | | Number of Individuals Covered | 460 | | Insurance policy start date | 2017-06-01 | | Insurance policy end date | 2018-05-31 | | Total amount of commissions paid to insurance broker | USD $9,981 | | Total amount of fees paid to insurance company | USD $2,193 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $124,589 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $9,981 | | Amount paid for insurance broker fees | 2193 | | Additional information about fees paid to insurance broker | BONUS | | Insurance broker organization code? | 3 |
|
| PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 ) |
| Policy contract number | 02081 |
| Policy instance | 1 |
| Insurance contract or identification number | 02081 | | Number of Individuals Covered | 193 | | Insurance policy start date | 2017-07-01 | | Insurance policy end date | 2018-06-30 | | Total amount of commissions paid to insurance broker | USD $14,901 | | Total amount of fees paid to insurance company | USD $74 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $148,115 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $14,901 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Additional information about fees paid to insurance broker | THIRD PARTY ADMINISTRATION FEES |
|
| CONTINENTAL AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71730 ) |
| Policy contract number | 21393 |
| Policy instance | 4 |
| Insurance contract or identification number | 21393 | | Number of Individuals Covered | 103 | | Insurance policy start date | 2018-03-01 | | Insurance policy end date | 2019-02-28 | | Total amount of commissions paid to insurance broker | USD $6,921 | | Total amount of fees paid to insurance company | USD $0 | | Temporary Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENT, CRITICAL ILLNESS, HOSPITAL | | Welfare Benefit Premiums Paid to Carrier | USD $64,849 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $3,794 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 ) |
| Policy contract number | 28750 |
| Policy instance | 3 |
| Insurance contract or identification number | 28750 | | Number of Individuals Covered | 41 | | Insurance policy start date | 2017-08-01 | | Insurance policy end date | 2018-07-31 | | Total amount of commissions paid to insurance broker | USD $2,378 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | ACCIDENT | | Welfare Benefit Premiums Paid to Carrier | USD $12,487 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,378 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 ) |
| Policy contract number | 647149 |
| Policy instance | 2 |
| Insurance contract or identification number | 647149 | | Number of Individuals Covered | 163 | | Insurance policy start date | 2017-07-01 | | Insurance policy end date | 2018-06-30 | | Total amount of commissions paid to insurance broker | USD $3,333 | | Total amount of fees paid to insurance company | USD $376 | | Vision Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,333 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Additional information about fees paid to insurance broker | CONTINGENT COMPENSATION |
|
| STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 ) |
| Policy contract number | 647149 |
| Policy instance | 2 |
| Insurance contract or identification number | 647149 | | Number of Individuals Covered | 156 | | Insurance policy start date | 2016-06-01 | | Insurance policy end date | 2017-05-31 | | Total amount of commissions paid to insurance broker | USD $3,868 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 ) |
| Policy contract number | 647149 |
| Policy instance | 6 |
| Insurance contract or identification number | 647149 | | Number of Individuals Covered | 157 | | Insurance policy start date | 2017-06-01 | | Insurance policy end date | 2017-06-30 | | Total amount of commissions paid to insurance broker | USD $266 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 ) |
| Policy contract number | 1064647 |
| Policy instance | 5 |
| Insurance contract or identification number | 1064647 | | Number of Individuals Covered | 187 | | Insurance policy start date | 2016-06-01 | | Insurance policy end date | 2017-05-31 | | Total amount of commissions paid to insurance broker | USD $10,187 | | Total amount of fees paid to insurance company | USD $7,367 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $127,501 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| CONTINENTAL AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71730 ) |
| Policy contract number | 21393 |
| Policy instance | 4 |
| Insurance contract or identification number | 21393 | | Number of Individuals Covered | 94 | | Insurance policy start date | 2017-03-01 | | Insurance policy end date | 2018-02-28 | | Total amount of commissions paid to insurance broker | USD $9,845 | | Total amount of fees paid to insurance company | USD $0 | | Temporary Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENT, CRITICAL ILLNESS, HOSPITAL | | Welfare Benefit Premiums Paid to Carrier | USD $63,773 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 ) |
| Policy contract number | 28750 |
| Policy instance | 3 |
| Insurance contract or identification number | 28750 | | Number of Individuals Covered | 34 | | Insurance policy start date | 2016-08-01 | | Insurance policy end date | 2017-07-31 | | Total amount of commissions paid to insurance broker | USD $5,619 | | Total amount of fees paid to insurance company | USD $0 | | Temporary Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENT | | Welfare Benefit Premiums Paid to Carrier | USD $10,216 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 ) |
| Policy contract number | 02081 |
| Policy instance | 1 |
| Insurance contract or identification number | 02081 | | Number of Individuals Covered | 191 | | Insurance policy start date | 2016-07-01 | | Insurance policy end date | 2017-06-30 | | Total amount of commissions paid to insurance broker | USD $14,794 | | Total amount of fees paid to insurance company | USD $62 | | Life Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $290,304 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 ) |
| Policy contract number | 28750 |
| Policy instance | 6 |
| Insurance contract or identification number | 28750 | | Number of Individuals Covered | 34 | | Insurance policy start date | 2016-08-01 | | Insurance policy end date | 2017-07-31 | | Total amount of commissions paid to insurance broker | USD $5,619 | | 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 | No | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENT | | 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 $10,216 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,619 | | Insurance broker organization code? | 3 | | Insurance broker name | MARCOTTE INSURANCE AGENCY INC |
|
| STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 ) |
| Policy contract number | 647149 |
| Policy instance | 1 |
| Insurance contract or identification number | 647149 | | Number of Individuals Covered | 156 | | Insurance policy start date | 2016-06-01 | | Insurance policy end date | 2017-05-31 | | Total amount of commissions paid to insurance broker | USD $3,868 | | 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 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,294 | | Insurance broker organization code? | 3 | | Insurance broker name | NFP INSURANCE SERVICES INC |
|
| PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 ) |
| Policy contract number | 1064647 |
| Policy instance | 2 |
| Insurance contract or identification number | 1064647 | | Number of Individuals Covered | 187 | | Insurance policy start date | 2016-06-01 | | Insurance policy end date | 2017-05-31 | | Total amount of commissions paid to insurance broker | USD $10,187 | | Total amount of fees paid to insurance company | USD $7,367 | | 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 | | Welfare Benefit Premiums Paid to Carrier | USD $127,501 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $10,187 | | Amount paid for insurance broker fees | 7367 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker organization code? | 3 | | Insurance broker name | MARCOTTE INS AGENCY INC |
|
| HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93440 ) |
| Policy contract number | 404636 0010 |
| Policy instance | 3 |
| Insurance contract or identification number | 404636 0010 | | Number of Individuals Covered | 177 | | Insurance policy start date | 2017-04-01 | | Insurance policy end date | 2018-03-31 | | 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 | 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 $351,701 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 ) |
| Policy contract number | 02081 |
| Policy instance | 4 |
| Insurance contract or identification number | 02081 | | Number of Individuals Covered | 191 | | Insurance policy start date | 2016-07-01 | | Insurance policy end date | 2017-06-30 | | Total amount of commissions paid to insurance broker | USD $14,794 | | Total amount of fees paid to insurance company | USD $62 | | 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 | AD&D, SUPPLEMENTAL LIFE, DEPENDENT LIFE | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $290,304 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $14,794 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 62 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker name | AXA ASSISTANCE USA |
|
| CONTINENTAL AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71730 ) |
| Policy contract number | 0000021393 |
| Policy instance | 5 |
| Insurance contract or identification number | 0000021393 | | Number of Individuals Covered | 94 | | Insurance policy start date | 2017-03-01 | | Insurance policy end date | 2018-02-28 | | Total amount of commissions paid to insurance broker | USD $9,845 | | 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 | No | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENT, CRITICAL ILLNESS, HOSPITAL INDEMNITY | | 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 $63,773 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,640 | | Insurance broker organization code? | 3 | | Insurance broker name | CHRISTOPHER L MILLER |
|
| STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 ) |
| Policy contract number | 647149 |
| Policy instance | 7 |
| Insurance contract or identification number | 647149 | | Number of Individuals Covered | 0 | | Insurance policy start date | 2016-06-01 | | Insurance policy end date | 2017-05-31 | | 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 | 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 | | 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? | No |
|
| HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93440 ) |
| Policy contract number | 404636 0010 |
| Policy instance | 3 |
| Insurance contract or identification number | 404636 0010 | | Number of Individuals Covered | 181 | | Insurance policy start date | 2015-04-01 | | Insurance policy end date | 2016-03-31 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $314,496 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 ) |
| Policy contract number | 647149 |
| Policy instance | 1 |
| Insurance contract or identification number | 647149 | | Number of Individuals Covered | 147 | | Insurance policy start date | 2014-06-01 | | Insurance policy end date | 2015-05-31 | | Total amount of commissions paid to insurance broker | USD $3,283 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,543 | | Insurance broker organization code? | 3 | | Insurance broker name | MARCOTTE INS AGENCY INC |
|
| STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 ) |
| Policy contract number | 751946 |
| Policy instance | 2 |
| Insurance contract or identification number | 751946 | | Number of Individuals Covered | 179 | | Insurance policy start date | 2014-06-01 | | Insurance policy end date | 2015-05-31 | | Total amount of commissions paid to insurance broker | USD $11,621 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 $10,192 | | Insurance broker organization code? | 3 | | Insurance broker name | BOLER WOOD & ASSOCIATES |
|
| NATIONAL UNION (National Association of Insurance Commissioners NAIC id number: 19445 ) |
| Policy contract number | 947-1128 |
| Policy instance | 4 |
| Insurance contract or identification number | 947-1128 | | Number of Individuals Covered | 182 | | Insurance policy start date | 2015-04-01 | | Insurance policy end date | 2016-03-31 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ORGAN TRANSPLANT | | 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 $35,626 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 ) |
| Policy contract number | 02081 |
| Policy instance | 5 |
| Insurance contract or identification number | 02081 | | Number of Individuals Covered | 102 | | Insurance policy start date | 2014-07-01 | | Insurance policy end date | 2015-06-30 | | Total amount of commissions paid to insurance broker | USD $16,951 | | Total amount of fees paid to insurance company | USD $66 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | AD&D, SUPPLEMENTAL LIFE, DEPENDENT LIFE | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $137,212 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $14,211 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 66 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker name | AXA ASSISTANCE USA |
|
| PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 ) |
| Policy contract number | 02081 |
| Policy instance | 6 |
| Insurance contract or identification number | 02081 | | Number of Individuals Covered | 182 | | Insurance policy start date | 2013-07-01 | | Insurance policy end date | 2014-06-30 | | Total amount of commissions paid to insurance broker | USD $13,908 | | Total amount of fees paid to insurance company | USD $63 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | 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 $82,905 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $13,908 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 63 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker name | AXA ASSISTANCE, USA |
|
| STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 ) |
| Policy contract number | 647149 |
| Policy instance | 1 |
| Insurance contract or identification number | 647149 | | Number of Individuals Covered | 141 | | Insurance policy start date | 2013-06-01 | | Insurance policy end date | 2014-05-31 | | Total amount of commissions paid to insurance broker | USD $2,833 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,833 | | Insurance broker organization code? | 3 | | Insurance broker name | BOLER WOOD & ASSOCIATES |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 223065 |
| Policy instance | 2 |
| Insurance contract or identification number | 223065 | | Number of Individuals Covered | 175 | | Insurance policy start date | 2013-06-01 | | Insurance policy end date | 2014-05-31 | | Total amount of commissions paid to insurance broker | USD $8,142 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | | Welfare Benefit Premiums Paid to Carrier | USD $116,253 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,142 | | Insurance broker organization code? | 3 | | Insurance broker name | BOLER WOOD & ASSOCIATES |
|
| AIG MEDICAL EXCESS (National Association of Insurance Commissioners NAIC id number: 19445 ) |
| Policy contract number | 1209 |
| Policy instance | 4 |
| Insurance contract or identification number | 1209 | | Number of Individuals Covered | 176 | | Insurance policy start date | 2014-04-01 | | Insurance policy end date | 2015-03-31 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ORGAN TRANSPLANT | | 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 $34,467 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93440 ) |
| Policy contract number | 404636 0010 |
| Policy instance | 3 |
| Insurance contract or identification number | 404636 0010 | | Number of Individuals Covered | 176 | | Insurance policy start date | 2014-04-01 | | Insurance policy end date | 2015-03-31 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $287,924 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 ) |
| Policy contract number | 02081 |
| Policy instance | 5 |
| Insurance contract or identification number | 02081 | | Number of Individuals Covered | 108 | | Insurance policy start date | 2013-07-01 | | Insurance policy end date | 2014-06-30 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | SUPPLEMENTAL LIFE, DEPENDENT LIFE | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $48,664 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93440 ) |
| Policy contract number | 4046360010AGGSS |
| Policy instance | 6 |
| Insurance contract or identification number | 4046360010AGGSS | | Number of Individuals Covered | 177 | | Insurance policy start date | 2013-04-01 | | Insurance policy end date | 2014-03-31 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $271,375 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| AIG MEDICAL EXCESS (National Association of Insurance Commissioners NAIC id number: 19445 ) |
| Policy contract number | 1209 |
| Policy instance | 5 |
| Insurance contract or identification number | 1209 | | Number of Individuals Covered | 174 | | Insurance policy start date | 2013-04-01 | | Insurance policy end date | 2014-03-31 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ORGAN TRANSPLANT | | 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 $33,238 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93440 ) |
| Policy contract number | 1209 |
| Policy instance | 4 |
| Insurance contract or identification number | 1209 | | Number of Individuals Covered | 174 | | Insurance policy start date | 2013-04-01 | | Insurance policy end date | 2014-03-31 | | Total amount of commissions paid to insurance broker | USD $46,789 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $269,633 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $31,645 | | Insurance broker organization code? | 3 | | Insurance broker name | CYPRESS BENEFITS ADMINISTRATORS, LL |
|
| PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 ) |
| Policy contract number | 02081 |
| Policy instance | 3 |
| Insurance contract or identification number | 02081 | | Number of Individuals Covered | 176 | | Insurance policy start date | 2012-07-01 | | Insurance policy end date | 2013-06-30 | | Total amount of commissions paid to insurance broker | USD $12,881 | | Total amount of fees paid to insurance company | USD $60 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | AD&D, SUPPLEMENTAL LIFE | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $118,434 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $12,881 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 60 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker name | AXA ASSISTANCE, USA |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 223065 |
| Policy instance | 2 |
| Insurance contract or identification number | 223065 | | Number of Individuals Covered | 175 | | Insurance policy start date | 2012-06-01 | | Insurance policy end date | 2013-05-31 | | Total amount of commissions paid to insurance broker | USD $8,057 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | | Welfare Benefit Premiums Paid to Carrier | USD $115,100 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,057 | | Insurance broker organization code? | 3 | | Insurance broker name | BOLER WOOD & ASSOCIATES |
|
| STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 ) |
| Policy contract number | 647149 |
| Policy instance | 1 |
| Insurance contract or identification number | 647149 | | Number of Individuals Covered | 137 | | Insurance policy start date | 2012-06-01 | | Insurance policy end date | 2013-05-31 | | Total amount of commissions paid to insurance broker | USD $2,563 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,563 | | Insurance broker organization code? | 3 | | Insurance broker name | BOLER WOOD & ASSOCIATES |
|
