FOUR B CORP. BALLS PRICE CHOPPER has sponsored the creation of one or more 401k plans.
Additional information about FOUR B CORP. BALLS PRICE CHOPPER
Submission information for form 5500 for 401k plan BALLS PRICE CHOPPER HEN HOUSE EMPLOYEE BENEFIT PLAN TRUST
401k plan membership statisitcs for BALLS PRICE CHOPPER HEN HOUSE EMPLOYEE BENEFIT PLAN TRUST
| Measure | Date | Value |
|---|
| 2017 : BALLS PRICE CHOPPER HEN HOUSE EMPLOYEE BENEFIT PLAN TRUST 2017 401k financial data |
|---|
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2017-06-30 | $0 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2017-06-30 | $995,076 |
| Total income from all sources (including contributions) | 2017-06-30 | $12,111,807 |
| Total of all expenses incurred | 2017-06-30 | $12,111,807 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2017-06-30 | $11,073,802 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2017-06-30 | $12,111,807 |
| Value of total assets at end of year | 2017-06-30 | $0 |
| Value of total assets at beginning of year | 2017-06-30 | $995,076 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2017-06-30 | $1,038,005 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2017-06-30 | No |
| Was this plan covered by a fidelity bond | 2017-06-30 | Yes |
| Value of fidelity bond cover | 2017-06-30 | $1,000,000 |
| If this is an individual account plan, was there a blackout period | 2017-06-30 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2017-06-30 | No |
| Contributions received from participants | 2017-06-30 | $3,283,063 |
| Value of other receiveables (less allowance for doubtful accounts) at beginning of year | 2017-06-30 | $268,559 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2017-06-30 | No |
| Value of net assets at end of year (total assets less liabilities) | 2017-06-30 | $0 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2017-06-30 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2017-06-30 | No |
| Were any leases to which the plan was party in default or uncollectible | 2017-06-30 | No |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2017-06-30 | $707,771 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2017-06-30 | No |
| Was there a failure to transmit to the plan any participant contributions | 2017-06-30 | No |
| Has the plan failed to provide any benefit when due under the plan | 2017-06-30 | No |
| Contributions received in cash from employer | 2017-06-30 | $8,828,744 |
| Employer contributions (assets) at beginning of year | 2017-06-30 | $726,517 |
| Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers | 2017-06-30 | $10,366,031 |
| Contract administrator fees | 2017-06-30 | $1,038,005 |
| Liabilities. Value of benefit claims payable at beginning of year | 2017-06-30 | $995,076 |
| Did the plan have assets held for investment | 2017-06-30 | No |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2017-06-30 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2017-06-30 | No |
| Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d) | 2017-06-30 | No |
| Opinion of an independent qualified public accountant for this plan | 2017-06-30 | Unqualified |
| Accountancy firm name | 2017-06-30 | SAMYN & MARTIN, LLC |
| Accountancy firm EIN | 2017-06-30 | 431679261 |
| 2016 : BALLS PRICE CHOPPER HEN HOUSE EMPLOYEE BENEFIT PLAN TRUST 2016 401k financial data |
|---|
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2016-06-30 | $995,076 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2016-06-30 | $480,015 |
| Total income from all sources (including contributions) | 2016-06-30 | $13,085,191 |
| Total of all expenses incurred | 2016-06-30 | $13,085,191 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2016-06-30 | $12,189,125 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2016-06-30 | $13,085,191 |
| Value of total assets at end of year | 2016-06-30 | $995,076 |
| Value of total assets at beginning of year | 2016-06-30 | $480,015 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2016-06-30 | $896,066 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2016-06-30 | No |
| Was this plan covered by a fidelity bond | 2016-06-30 | Yes |
| Value of fidelity bond cover | 2016-06-30 | $1,000,000 |
| If this is an individual account plan, was there a blackout period | 2016-06-30 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2016-06-30 | No |
| Contributions received from participants | 2016-06-30 | $3,190,808 |
| Value of other receiveables (less allowance for doubtful accounts) at end of year | 2016-06-30 | $268,559 |
| Liabilities. Value of operating payables at beginning of year | 2016-06-30 | $104,498 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2016-06-30 | No |
| Value of net assets at end of year (total assets less liabilities) | 2016-06-30 | $0 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2016-06-30 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2016-06-30 | No |
| Were any leases to which the plan was party in default or uncollectible | 2016-06-30 | No |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2016-06-30 | $541,107 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2016-06-30 | No |
| Was there a failure to transmit to the plan any participant contributions | 2016-06-30 | No |
| Has the plan failed to provide any benefit when due under the plan | 2016-06-30 | No |
| Contributions received in cash from employer | 2016-06-30 | $9,894,383 |
| Employer contributions (assets) at end of year | 2016-06-30 | $726,517 |
| Employer contributions (assets) at beginning of year | 2016-06-30 | $480,015 |
| Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers | 2016-06-30 | $11,648,018 |
| Contract administrator fees | 2016-06-30 | $896,066 |
| Liabilities. Value of benefit claims payable at end of year | 2016-06-30 | $995,076 |
| Liabilities. Value of benefit claims payable at beginning of year | 2016-06-30 | $375,517 |
| Did the plan have assets held for investment | 2016-06-30 | No |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2016-06-30 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2016-06-30 | No |
| Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d) | 2016-06-30 | No |
| Opinion of an independent qualified public accountant for this plan | 2016-06-30 | Unqualified |
| Accountancy firm name | 2016-06-30 | SAMYN & MARTIN, LLC |
| Accountancy firm EIN | 2016-06-30 | 431679261 |
| 2015 : BALLS PRICE CHOPPER HEN HOUSE EMPLOYEE BENEFIT PLAN TRUST 2015 401k financial data |
|---|
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2015-06-30 | $480,015 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2015-06-30 | $465,164 |
| Total income from all sources (including contributions) | 2015-06-30 | $13,207,304 |
| Total of all expenses incurred | 2015-06-30 | $13,238,688 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2015-06-30 | $12,622,479 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2015-06-30 | $13,207,304 |
| Value of total assets at end of year | 2015-06-30 | $480,015 |
| Value of total assets at beginning of year | 2015-06-30 | $496,548 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2015-06-30 | $616,209 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2015-06-30 | No |
| Was this plan covered by a fidelity bond | 2015-06-30 | Yes |
| Value of fidelity bond cover | 2015-06-30 | $1,000,000 |
| If this is an individual account plan, was there a blackout period | 2015-06-30 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2015-06-30 | No |
| Contributions received from participants | 2015-06-30 | $3,078,738 |
| Value of other receiveables (less allowance for doubtful accounts) at beginning of year | 2015-06-30 | $31,384 |
| Liabilities. Value of operating payables at end of year | 2015-06-30 | $104,498 |
| Liabilities. Value of operating payables at beginning of year | 2015-06-30 | $125,606 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2015-06-30 | No |
| Value of net income/loss | 2015-06-30 | $-31,384 |
| Value of net assets at end of year (total assets less liabilities) | 2015-06-30 | $0 |
| Value of net assets at beginning of year (total assets less liabilities) | 2015-06-30 | $31,384 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2015-06-30 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2015-06-30 | No |
| Were any leases to which the plan was party in default or uncollectible | 2015-06-30 | No |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2015-06-30 | $334,311 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2015-06-30 | No |
| Was there a failure to transmit to the plan any participant contributions | 2015-06-30 | No |
| Has the plan failed to provide any benefit when due under the plan | 2015-06-30 | No |
| Contributions received in cash from employer | 2015-06-30 | $10,128,566 |
| Employer contributions (assets) at end of year | 2015-06-30 | $480,015 |
| Employer contributions (assets) at beginning of year | 2015-06-30 | $465,164 |
| Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers | 2015-06-30 | $12,288,168 |
| Contract administrator fees | 2015-06-30 | $616,209 |
| Liabilities. Value of benefit claims payable at end of year | 2015-06-30 | $375,517 |
| Liabilities. Value of benefit claims payable at beginning of year | 2015-06-30 | $339,558 |
| Did the plan have assets held for investment | 2015-06-30 | No |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2015-06-30 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2015-06-30 | No |
| Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d) | 2015-06-30 | No |
| Opinion of an independent qualified public accountant for this plan | 2015-06-30 | Unqualified |
| Accountancy firm name | 2015-06-30 | SAMYN & MARTIN, LLC |
| Accountancy firm EIN | 2015-06-30 | 431679261 |
| 2014 : BALLS PRICE CHOPPER HEN HOUSE EMPLOYEE BENEFIT PLAN TRUST 2014 401k financial data |
|---|
| Total unrealized appreciation/depreciation of assets | 2014-06-30 | $0 |
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2014-06-30 | $465,164 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2014-06-30 | $432,607 |
| Total income from all sources (including contributions) | 2014-06-30 | $13,117,817 |
| Total loss/gain on sale of assets | 2014-06-30 | $0 |
| Total of all expenses incurred | 2014-06-30 | $13,216,636 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2014-06-30 | $12,890,000 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2014-06-30 | $13,117,817 |
| Value of total assets at end of year | 2014-06-30 | $496,548 |
| Value of total assets at beginning of year | 2014-06-30 | $562,810 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2014-06-30 | $326,636 |
| Total interest from all sources | 2014-06-30 | $0 |
| Total dividends received (eg from common stock, registered investment company shares) | 2014-06-30 | $0 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2014-06-30 | Yes |
| Value of any plan assets that reverted to the employer resulting from resoluton to terminate the plan | 2014-06-30 | $0 |
| Was this plan covered by a fidelity bond | 2014-06-30 | Yes |
| Value of fidelity bond cover | 2014-06-30 | $1,000,000 |
| If this is an individual account plan, was there a blackout period | 2014-06-30 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2014-06-30 | No |
| Contributions received from participants | 2014-06-30 | $3,170,787 |
| Value of other receiveables (less allowance for doubtful accounts) at end of year | 2014-06-30 | $31,384 |
| Value of other receiveables (less allowance for doubtful accounts) at beginning of year | 2014-06-30 | $130,203 |
| Liabilities. Value of operating payables at end of year | 2014-06-30 | $125,606 |
| Liabilities. Value of operating payables at beginning of year | 2014-06-30 | $70,207 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2014-06-30 | No |
| Value of net income/loss | 2014-06-30 | $-98,819 |
| Value of net assets at end of year (total assets less liabilities) | 2014-06-30 | $31,384 |
| Value of net assets at beginning of year (total assets less liabilities) | 2014-06-30 | $130,203 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2014-06-30 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2014-06-30 | No |
| Were any leases to which the plan was party in default or uncollectible | 2014-06-30 | No |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2014-06-30 | $359,935 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2014-06-30 | No |
| Was there a failure to transmit to the plan any participant contributions | 2014-06-30 | No |
| Has the plan failed to provide any benefit when due under the plan | 2014-06-30 | No |
| Contributions received in cash from employer | 2014-06-30 | $9,947,030 |
| Employer contributions (assets) at end of year | 2014-06-30 | $465,164 |
| Employer contributions (assets) at beginning of year | 2014-06-30 | $432,607 |
| Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers | 2014-06-30 | $12,530,065 |
| Contract administrator fees | 2014-06-30 | $326,636 |
| Liabilities. Value of benefit claims payable at end of year | 2014-06-30 | $339,558 |
| Liabilities. Value of benefit claims payable at beginning of year | 2014-06-30 | $362,400 |
| Did the plan have assets held for investment | 2014-06-30 | No |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2014-06-30 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2014-06-30 | No |
| Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d) | 2014-06-30 | No |
| Opinion of an independent qualified public accountant for this plan | 2014-06-30 | Unqualified |
| Accountancy firm name | 2014-06-30 | SAMYN & MARTIN, LLC |
| Accountancy firm EIN | 2014-06-30 | 431679261 |
| 2013 : BALLS PRICE CHOPPER HEN HOUSE EMPLOYEE BENEFIT PLAN TRUST 2013 401k financial data |
|---|
| Total unrealized appreciation/depreciation of assets | 2013-06-30 | $0 |
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2013-06-30 | $432,607 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2013-06-30 | $317,024 |
| Total income from all sources (including contributions) | 2013-06-30 | $11,914,178 |
| Total loss/gain on sale of assets | 2013-06-30 | $0 |
| Total of all expenses incurred | 2013-06-30 | $12,024,567 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2013-06-30 | $11,694,213 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2013-06-30 | $11,914,178 |
| Value of total assets at end of year | 2013-06-30 | $562,810 |
| Value of total assets at beginning of year | 2013-06-30 | $557,616 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2013-06-30 | $330,354 |
| Total interest from all sources | 2013-06-30 | $0 |
| Total dividends received (eg from common stock, registered investment company shares) | 2013-06-30 | $0 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2013-06-30 | No |
| Was this plan covered by a fidelity bond | 2013-06-30 | Yes |
| Value of fidelity bond cover | 2013-06-30 | $1,000,000 |
| If this is an individual account plan, was there a blackout period | 2013-06-30 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2013-06-30 | No |
| Contributions received from participants | 2013-06-30 | $2,853,947 |
| Value of other receiveables (less allowance for doubtful accounts) at end of year | 2013-06-30 | $130,203 |
| Value of other receiveables (less allowance for doubtful accounts) at beginning of year | 2013-06-30 | $240,592 |
| Liabilities. Value of operating payables at end of year | 2013-06-30 | $70,207 |
| Liabilities. Value of operating payables at beginning of year | 2013-06-30 | $17,355 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2013-06-30 | No |
| Value of net income/loss | 2013-06-30 | $-110,389 |
| Value of net assets at end of year (total assets less liabilities) | 2013-06-30 | $130,203 |
| Value of net assets at beginning of year (total assets less liabilities) | 2013-06-30 | $240,592 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2013-06-30 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2013-06-30 | No |
| Were any leases to which the plan was party in default or uncollectible | 2013-06-30 | No |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2013-06-30 | $356,406 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2013-06-30 | No |
| Was there a failure to transmit to the plan any participant contributions | 2013-06-30 | No |
| Has the plan failed to provide any benefit when due under the plan | 2013-06-30 | No |
| Contributions received in cash from employer | 2013-06-30 | $9,060,231 |
| Employer contributions (assets) at end of year | 2013-06-30 | $432,607 |
| Employer contributions (assets) at beginning of year | 2013-06-30 | $317,024 |
| Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers | 2013-06-30 | $11,337,807 |
| Contract administrator fees | 2013-06-30 | $330,354 |
| Liabilities. Value of benefit claims payable at end of year | 2013-06-30 | $362,400 |
| Liabilities. Value of benefit claims payable at beginning of year | 2013-06-30 | $299,669 |
| Did the plan have assets held for investment | 2013-06-30 | No |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2013-06-30 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2013-06-30 | No |
| Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d) | 2013-06-30 | No |
| Opinion of an independent qualified public accountant for this plan | 2013-06-30 | Unqualified |
| Accountancy firm name | 2013-06-30 | WEAVER MARTIN & SAMYN, LLC |
| Accountancy firm EIN | 2013-06-30 | 431679261 |
| 2012 : BALLS PRICE CHOPPER HEN HOUSE EMPLOYEE BENEFIT PLAN TRUST 2012 401k financial data |
|---|
| Total unrealized appreciation/depreciation of assets | 2012-06-30 | $0 |
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2012-06-30 | $317,024 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2012-06-30 | $163,414 |
| Total income from all sources (including contributions) | 2012-06-30 | $14,446,524 |
| Total loss/gain on sale of assets | 2012-06-30 | $0 |
| Total of all expenses incurred | 2012-06-30 | $14,205,932 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2012-06-30 | $13,851,152 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2012-06-30 | $14,446,524 |
| Value of total assets at end of year | 2012-06-30 | $557,616 |
| Value of total assets at beginning of year | 2012-06-30 | $163,414 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2012-06-30 | $354,780 |
| Total interest from all sources | 2012-06-30 | $0 |
| Total dividends received (eg from common stock, registered investment company shares) | 2012-06-30 | $0 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2012-06-30 | No |
| Was this plan covered by a fidelity bond | 2012-06-30 | Yes |
| Value of fidelity bond cover | 2012-06-30 | $1,000,000 |
| If this is an individual account plan, was there a blackout period | 2012-06-30 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2012-06-30 | No |
| Contributions received from participants | 2012-06-30 | $2,648,142 |
| Value of other receiveables (less allowance for doubtful accounts) at end of year | 2012-06-30 | $240,592 |
| Value of other receiveables (less allowance for doubtful accounts) at beginning of year | 2012-06-30 | $0 |
| Liabilities. Value of operating payables at end of year | 2012-06-30 | $17,355 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2012-06-30 | No |
| Value of net income/loss | 2012-06-30 | $240,592 |
| Value of net assets at end of year (total assets less liabilities) | 2012-06-30 | $240,592 |
| Value of net assets at beginning of year (total assets less liabilities) | 2012-06-30 | $0 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2012-06-30 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2012-06-30 | No |
| Were any leases to which the plan was party in default or uncollectible | 2012-06-30 | No |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2012-06-30 | $350,479 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2012-06-30 | No |
| Was there a failure to transmit to the plan any participant contributions | 2012-06-30 | No |
| Has the plan failed to provide any benefit when due under the plan | 2012-06-30 | No |
| Contributions received in cash from employer | 2012-06-30 | $11,798,382 |
| Employer contributions (assets) at end of year | 2012-06-30 | $317,024 |
| Employer contributions (assets) at beginning of year | 2012-06-30 | $163,414 |
| Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers | 2012-06-30 | $13,500,673 |
| Contract administrator fees | 2012-06-30 | $354,780 |
| Liabilities. Value of benefit claims payable at end of year | 2012-06-30 | $299,669 |
| Liabilities. Value of benefit claims payable at beginning of year | 2012-06-30 | $163,414 |
| Did the plan have assets held for investment | 2012-06-30 | No |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2012-06-30 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2012-06-30 | No |
| Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d) | 2012-06-30 | No |
| Opinion of an independent qualified public accountant for this plan | 2012-06-30 | Unqualified |
| Accountancy firm name | 2012-06-30 | WEAVER MARTIN & SAMYN, LLC |
| Accountancy firm EIN | 2012-06-30 | 431679261 |
| 2011 : BALLS PRICE CHOPPER HEN HOUSE EMPLOYEE BENEFIT PLAN TRUST 2011 401k financial data |
|---|
| Total unrealized appreciation/depreciation of assets | 2011-06-30 | $0 |
| Total transfer of assets to this plan | 2011-06-30 | $0 |
| Total transfer of assets from this plan | 2011-06-30 | $0 |
| Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2011-06-30 | $163,414 |
| Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities) | 2011-06-30 | $539,739 |
| Total income from all sources (including contributions) | 2011-06-30 | $10,292,129 |
| Total loss/gain on sale of assets | 2011-06-30 | $0 |
| Total of all expenses incurred | 2011-06-30 | $10,292,129 |
| Benefit payments and payments to participlants,beneficiaries,insurance carriers and others | 2011-06-30 | $9,910,765 |
| Total contributions o plan (from employers,participants, others, non cash contrinutions) | 2011-06-30 | $10,292,129 |
| Value of total assets at end of year | 2011-06-30 | $163,414 |
| Value of total assets at beginning of year | 2011-06-30 | $539,739 |
| Total of administrative expenses incurred including professional, contract, advisory and management fees | 2011-06-30 | $381,364 |
| Total interest from all sources | 2011-06-30 | $0 |
| Total dividends received (eg from common stock, registered investment company shares) | 2011-06-30 | $0 |
| Has a resolution to terminate the plan been adopted during the plan year or any prior plan year | 2011-06-30 | No |
| Was this plan covered by a fidelity bond | 2011-06-30 | Yes |
| Value of fidelity bond cover | 2011-06-30 | $1,000,000 |
| If this is an individual account plan, was there a blackout period | 2011-06-30 | No |
| Were there any nonexempt tranactions with any party-in-interest | 2011-06-30 | No |
| Contributions received from participants | 2011-06-30 | $2,482,546 |
| Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser | 2011-06-30 | No |
| Value of net income/loss | 2011-06-30 | $0 |
| Value of net assets at end of year (total assets less liabilities) | 2011-06-30 | $0 |
| Value of net assets at beginning of year (total assets less liabilities) | 2011-06-30 | $0 |
| Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond) | 2011-06-30 | No |
| Were any loans by the plan or fixed income obligations due to the plan in default | 2011-06-30 | No |
| Were any leases to which the plan was party in default or uncollectible | 2011-06-30 | No |
| Value of funds held in insurance company general accounts (unallocated contracts) at end of year | 2011-06-30 | $0 |
| Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year | 2011-06-30 | $0 |
| Expenses. Payments to insurance carriers foe the provision of benefits | 2011-06-30 | $680,995 |
| Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets | 2011-06-30 | No |
| Was there a failure to transmit to the plan any participant contributions | 2011-06-30 | No |
| Has the plan failed to provide any benefit when due under the plan | 2011-06-30 | No |
| Contributions received in cash from employer | 2011-06-30 | $7,809,583 |
| Employer contributions (assets) at end of year | 2011-06-30 | $163,414 |
| Employer contributions (assets) at beginning of year | 2011-06-30 | $539,739 |
| Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers | 2011-06-30 | $9,229,770 |
| Contract administrator fees | 2011-06-30 | $381,364 |
| Liabilities. Value of benefit claims payable at end of year | 2011-06-30 | $163,414 |
| Liabilities. Value of benefit claims payable at beginning of year | 2011-06-30 | $539,739 |
| Did the plan have assets held for investment | 2011-06-30 | No |
| Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser | 2011-06-30 | No |
| Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC | 2011-06-30 | No |
| Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d) | 2011-06-30 | No |
| Opinion of an independent qualified public accountant for this plan | 2011-06-30 | Unqualified |
| Accountancy firm name | 2011-06-30 | WEAVER MARTIN & SAMYN, LLC |
| Accountancy firm EIN | 2011-06-30 | 431679261 |
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 900214 |
| Policy instance | 2 |
| Insurance contract or identification number | 900214 | | Number of Individuals Covered | 612 | | Insurance policy start date | 2021-07-01 | | Insurance policy end date | 2022-06-30 | | Total amount of commissions paid to insurance broker | USD $73,015 | | Other welfare benefits provided | CRITICAL ILLNESS AND ACCIDENT | | Welfare Benefit Premiums Paid to Carrier | USD $211,279 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $73,015 | | Insurance broker organization code? | 3 |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 900214 |
| Policy instance | 1 |
| Insurance contract or identification number | 900214 | | Number of Individuals Covered | 210 | | Insurance policy start date | 2021-07-01 | | Insurance policy end date | 2022-06-30 | | Total amount of commissions paid to insurance broker | USD $2,802 | | Other welfare benefits provided | VOLUNTARY LTD | | Welfare Benefit Premiums Paid to Carrier | USD $23,609 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,578 | | Insurance broker organization code? | 3 |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 900214 |
| Policy instance | 3 |
| Insurance contract or identification number | 900214 | | Number of Individuals Covered | 1349 | | Insurance policy start date | 2021-07-01 | | Insurance policy end date | 2022-06-30 | | Total amount of commissions paid to insurance broker | USD $673 | | Total amount of fees paid to insurance company | USD $924 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $34,398 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $619 | | Amount paid for insurance broker fees | 786 | | Additional information about fees paid to insurance broker | BONUS | | Insurance broker organization code? | 3 |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 900214 |
| Policy instance | 4 |
| Insurance contract or identification number | 900214 | | Number of Individuals Covered | 1195 | | Insurance policy start date | 2021-07-01 | | Insurance policy end date | 2022-06-30 | | Total amount of commissions paid to insurance broker | USD $175 | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $8,931 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $161 | | Insurance broker organization code? | 3 |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 900214 |
| Policy instance | 5 |
| Insurance contract or identification number | 900214 | | Number of Individuals Covered | 307 | | Insurance policy start date | 2021-07-01 | | Insurance policy end date | 2022-06-30 | | Total amount of commissions paid to insurance broker | USD $1,036 | | Total amount of fees paid to insurance company | USD $1,840 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $52,889 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $953 | | Amount paid for insurance broker fees | 1566 | | Additional information about fees paid to insurance broker | BONUS | | Insurance broker organization code? | 3 |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 900214 |
| Policy instance | 6 |
| Insurance contract or identification number | 900214 | | Number of Individuals Covered | 522 | | Insurance policy start date | 2021-07-01 | | Insurance policy end date | 2022-06-30 | | Total amount of commissions paid to insurance broker | USD $62,793 | | Total amount of fees paid to insurance company | USD $5,130 | | Other welfare benefits provided | VOLUNTARY LIFE | | Welfare Benefit Premiums Paid to Carrier | USD $253,608 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $57,770 | | Amount paid for insurance broker fees | 4366 | | Additional information about fees paid to insurance broker | BONUS | | Insurance broker organization code? | 3 |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 900214 |
| Policy instance | 7 |
| Insurance contract or identification number | 900214 | | Number of Individuals Covered | 357 | | Insurance policy start date | 2021-07-01 | | Insurance policy end date | 2022-06-30 | | Total amount of commissions paid to insurance broker | USD $2,284 | | Other welfare benefits provided | VOLUNTARY AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $9,376 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,101 | | Insurance broker organization code? | 3 |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 30093480 |
| Policy instance | 8 |
| Insurance contract or identification number | 30093480 | | Number of Individuals Covered | 1158 | | Insurance policy start date | 2021-07-01 | | Insurance policy end date | 2022-06-30 | | Vision Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 941866 |
| Policy instance | 9 |
| Insurance contract or identification number | 941866 | | Number of Individuals Covered | 188 | | Insurance policy start date | 2021-07-01 | | Insurance policy end date | 2022-06-30 | | Total amount of commissions paid to insurance broker | USD $22,658 | | Welfare Benefit Premiums Paid to Carrier | USD $60,500 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $22,658 | | Insurance broker organization code? | 3 |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 900214 |
| Policy instance | 1 |
| Insurance contract or identification number | 900214 | | Number of Individuals Covered | 223 | | Insurance policy start date | 2020-07-01 | | Insurance policy end date | 2021-06-30 | | Total amount of commissions paid to insurance broker | USD $3,084 | | Other welfare benefits provided | VOLUNTARY LTD | | Welfare Benefit Premiums Paid to Carrier | USD $26,314 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,816 | | Insurance broker organization code? | 3 |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 900214 |
| Policy instance | 2 |
| Insurance contract or identification number | 900214 | | Number of Individuals Covered | 646 | | Insurance policy start date | 2020-07-01 | | Insurance policy end date | 2021-06-30 | | Total amount of commissions paid to insurance broker | USD $89,211 | | Other welfare benefits provided | CRITICAL ILLNESS AND ACCIDENT | | Welfare Benefit Premiums Paid to Carrier | USD $261,131 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $82,565 | | Insurance broker organization code? | 3 |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 900214 |
| Policy instance | 4 |
| Insurance contract or identification number | 900214 | | Number of Individuals Covered | 1166 | | Insurance policy start date | 2020-07-01 | | Insurance policy end date | 2021-06-30 | | Total amount of commissions paid to insurance broker | USD $184 | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $9,231 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $155 | | Insurance broker organization code? | 3 |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 900214 |
| Policy instance | 6 |
| Insurance contract or identification number | 900214 | | Number of Individuals Covered | 543 | | Insurance policy start date | 2020-07-01 | | Insurance policy end date | 2021-06-30 | | Total amount of commissions paid to insurance broker | USD $58,621 | | Other welfare benefits provided | VOLUNTARY LIFE | | Welfare Benefit Premiums Paid to Carrier | USD $235,175 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $53,931 | | Insurance broker organization code? | 3 |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 900214 |
| Policy instance | 5 |
| Insurance contract or identification number | 900214 | | Number of Individuals Covered | 318 | | Insurance policy start date | 2020-07-01 | | Insurance policy end date | 2021-06-30 | | Total amount of commissions paid to insurance broker | USD $1,239 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $62,220 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,047 | | Insurance broker organization code? | 3 |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 900214 |
| Policy instance | 7 |
| Insurance contract or identification number | 900214 | | Number of Individuals Covered | 357 | | Insurance policy start date | 2020-07-01 | | Insurance policy end date | 2021-06-30 | | Total amount of commissions paid to insurance broker | USD $3,612 | | Other welfare benefits provided | VOLUNTARY AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $14,525 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,323 | | Insurance broker organization code? | 3 |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 30093480 |
| Policy instance | 8 |
| Insurance contract or identification number | 30093480 | | Number of Individuals Covered | 1163 | | Insurance policy start date | 2020-07-01 | | Insurance policy end date | 2021-06-30 | | Vision Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 941866 |
| Policy instance | 9 |
| Insurance contract or identification number | 941866 | | Number of Individuals Covered | 160 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-06-30 | | Total amount of commissions paid to insurance broker | USD $6,841 | | Welfare Benefit Premiums Paid to Carrier | USD $29,160 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,841 | | Insurance broker organization code? | 3 |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 900214 |
| Policy instance | 3 |
| Insurance contract or identification number | 900214 | | Number of Individuals Covered | 1288 | | Insurance policy start date | 2020-07-01 | | Insurance policy end date | 2021-06-30 | | Total amount of commissions paid to insurance broker | USD $743 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $37,018 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $625 | | Insurance broker organization code? | 3 |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 900214 |
| Policy instance | 5 |
| Insurance contract or identification number | 900214 | | Number of Individuals Covered | 1237 | | Insurance policy start date | 2019-07-01 | | Insurance policy end date | 2020-06-30 | | Total amount of commissions paid to insurance broker | USD $79 | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $8,421 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $79 | | Insurance broker organization code? | 3 |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 900214 |
| Policy instance | 7 |
| Insurance contract or identification number | 900214 | | Number of Individuals Covered | 575 | | Insurance policy start date | 2019-07-01 | | Insurance policy end date | 2020-06-30 | | Total amount of commissions paid to insurance broker | USD $48,840 | | Other welfare benefits provided | VOLUNTARY LIFE | | Welfare Benefit Premiums Paid to Carrier | USD $206,676 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $43,016 | | Insurance broker organization code? | 3 |
|
| SYMETRA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68608 ) |
| Policy contract number | 01-017493-00 |
| Policy instance | 2 |
| Insurance contract or identification number | 01-017493-00 | | Number of Individuals Covered | 311 | | Insurance policy start date | 2019-07-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $2,703 | | Total amount of fees paid to insurance company | USD $711 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $27,034 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,232 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 711 | | Additional information about fees paid to insurance broker | GROUP VOLUME BONUS |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 900214 |
| Policy instance | 3 |
| Insurance contract or identification number | 900214 | | Number of Individuals Covered | 556 | | Insurance policy start date | 2019-07-01 | | Insurance policy end date | 2020-06-30 | | Total amount of commissions paid to insurance broker | USD $61,326 | | Other welfare benefits provided | CRITICAL ILLNESS AND ACCIDENT | | Welfare Benefit Premiums Paid to Carrier | USD $270,951 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $55,274 | | Insurance broker organization code? | 3 |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 900214 |
| Policy instance | 4 |
| Insurance contract or identification number | 900214 | | Number of Individuals Covered | 1712 | | Insurance policy start date | 2019-07-01 | | Insurance policy end date | 2020-06-30 | | Total amount of commissions paid to insurance broker | USD $441 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $43,804 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $441 | | Insurance broker organization code? | 3 |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 900214 |
| Policy instance | 6 |
| Insurance contract or identification number | 900214 | | Number of Individuals Covered | 325 | | Insurance policy start date | 2019-07-01 | | Insurance policy end date | 2020-06-30 | | Total amount of commissions paid to insurance broker | USD $691 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $68,885 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $691 | | Insurance broker organization code? | 3 |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 ) |
| Policy contract number | 30093480 |
| Policy instance | 9 |
| Insurance contract or identification number | 30093480 | | Number of Individuals Covered | 1198 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-06-30 | | Vision Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 900214 |
| Policy instance | 1 |
| Insurance contract or identification number | 900214 | | Number of Individuals Covered | 205 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-06-30 | | Total amount of commissions paid to insurance broker | USD $1,204 | | Other welfare benefits provided | VOLUNTARY LTD | | Welfare Benefit Premiums Paid to Carrier | USD $10,025 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $999 | | Insurance broker organization code? | 3 |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 900214 |
| Policy instance | 8 |
| Insurance contract or identification number | 900214 | | Number of Individuals Covered | 357 | | Insurance policy start date | 2019-07-01 | | Insurance policy end date | 2020-06-30 | | Total amount of commissions paid to insurance broker | USD $2,615 | | Other welfare benefits provided | VOLUNTARY AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $11,130 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,295 | | Insurance broker organization code? | 3 |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 900214 |
| Policy instance | 9 |
| Insurance contract or identification number | 900214 | | Number of Individuals Covered | 1279 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-06-30 | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $3,941 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | LK 960866 |
| Policy instance | 3 |
| Insurance contract or identification number | LK 960866 | | Number of Individuals Covered | 297 | | Insurance policy start date | 2018-07-01 | | Insurance policy end date | 2018-12-31 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $20,417 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | FLX961043 |
| Policy instance | 1 |
| Insurance contract or identification number | FLX961043 | | Number of Individuals Covered | 1277 | | Insurance policy start date | 2018-07-01 | | Insurance policy end date | 2018-12-31 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $29,608 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | OK 961096 |
| Policy instance | 5 |
| Insurance contract or identification number | OK 961096 | | Number of Individuals Covered | 1268 | | Insurance policy start date | 2018-07-01 | | Insurance policy end date | 2018-12-31 | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $3,593 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | OK 963868 |
| Policy instance | 6 |
| Insurance contract or identification number | OK 963868 | | Number of Individuals Covered | 210 | | Insurance policy start date | 2018-07-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $4,226 | | Other welfare benefits provided | VOLUNTARY AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $3,881 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,226 | | Insurance broker organization code? | 3 |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 900214 |
| Policy instance | 12 |
| Insurance contract or identification number | 900214 | | Number of Individuals Covered | 356 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-06-30 | | Total amount of commissions paid to insurance broker | USD $990 | | Other welfare benefits provided | VOLUNTARY AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $5,371 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $990 | | Insurance broker organization code? | 3 |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 900214 |
| Policy instance | 11 |
| Insurance contract or identification number | 900214 | | Number of Individuals Covered | 362 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-06-30 | | Total amount of commissions paid to insurance broker | USD $17,293 | | Other welfare benefits provided | VOLUNTARY LIFE | | Welfare Benefit Premiums Paid to Carrier | USD $93,486 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $17,293 | | Insurance broker organization code? | 3 |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 900214 |
| Policy instance | 10 |
| Insurance contract or identification number | 900214 | | Number of Individuals Covered | 319 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-06-30 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $19,550 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 900214 |
| Policy instance | 7 |
| Insurance contract or identification number | 900214 | | Number of Individuals Covered | 547 | | Insurance policy start date | 2018-07-01 | | Insurance policy end date | 2019-06-30 | | Total amount of commissions paid to insurance broker | USD $44,035 | | Other welfare benefits provided | CRITICAL ILLNESS AND ACCIDENT | | Welfare Benefit Premiums Paid to Carrier | USD $290,451 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $44,035 | | Insurance broker organization code? | 3 |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 900214 |
| Policy instance | 8 |
| Insurance contract or identification number | 900214 | | Number of Individuals Covered | 1279 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-06-30 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $16,412 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | FLX962243 |
| Policy instance | 2 |
| Insurance contract or identification number | FLX962243 | | Number of Individuals Covered | 238 | | Insurance policy start date | 2018-07-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $16,146 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $71,760 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $16,146 | | Insurance broker organization code? | 3 |
|
| SYMETRA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68608 ) |
| Policy contract number | 01-017493-00 |
| Policy instance | 4 |
| Insurance contract or identification number | 01-017493-00 | | Number of Individuals Covered | 333 | | Insurance policy start date | 2018-07-01 | | Insurance policy end date | 2019-06-30 | | Total amount of commissions paid to insurance broker | USD $5,608 | | Total amount of fees paid to insurance company | USD $2,093 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $56,077 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,608 | | Amount paid for insurance broker fees | 2093 | | Additional information about fees paid to insurance broker | GROUP VOLUME BONUS | | Insurance broker organization code? | 3 |
|
| TRUSTMARK INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61425 ) |
| Policy contract number | 0365700000 |
| Policy instance | 7 |
| Insurance contract or identification number | 0365700000 | | Number of Individuals Covered | 357 | | Insurance policy start date | 2017-07-01 | | Insurance policy end date | 2017-10-01 | | Total amount of commissions paid to insurance broker | USD $7,390 | | Other welfare benefits provided | CANCER/CRITICAL ILLNESS | | Welfare Benefit Premiums Paid to Carrier | USD $27,347 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | FLX961043 |
| Policy instance | 1 |
| Insurance contract or identification number | FLX961043 | | Number of Individuals Covered | 2096 | | Insurance policy start date | 2017-07-01 | | Insurance policy end date | 2018-06-30 | | Total amount of fees paid to insurance company | USD $1,394 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $74,865 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | FLX962243 |
| Policy instance | 2 |
| Insurance contract or identification number | FLX962243 | | Number of Individuals Covered | 255 | | Insurance policy start date | 2017-07-01 | | Insurance policy end date | 2018-06-30 | | Total amount of commissions paid to insurance broker | USD $37,649 | | Total amount of fees paid to insurance company | USD $2,946 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $167,330 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | LK 960866 |
| Policy instance | 3 |
| Insurance contract or identification number | LK 960866 | | Number of Individuals Covered | 269 | | Insurance policy start date | 2017-07-01 | | Insurance policy end date | 2018-06-30 | | Total amount of fees paid to insurance company | USD $867 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $46,700 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| SYMETRA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68608 ) |
| Policy contract number | 01-017493-00 |
| Policy instance | 4 |
| Insurance contract or identification number | 01-017493-00 | | Number of Individuals Covered | 316 | | Insurance policy start date | 2017-09-01 | | Insurance policy end date | 2018-06-30 | | Total amount of commissions paid to insurance broker | USD $5,435 | | Total amount of fees paid to insurance company | USD $-468 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $54,353 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | OK 963868 |
| Policy instance | 6 |
| Insurance contract or identification number | OK 963868 | | Number of Individuals Covered | 310 | | Insurance policy start date | 2017-07-01 | | Insurance policy end date | 2018-06-30 | | Total amount of commissions paid to insurance broker | USD $2,118 | | Total amount of fees paid to insurance company | USD $175 | | Other welfare benefits provided | VOLUNTARY AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $9,412 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | OK 961096 |
| Policy instance | 5 |
| Insurance contract or identification number | OK 961096 | | Number of Individuals Covered | 1302 | | Insurance policy start date | 2017-07-01 | | Insurance policy end date | 2018-06-30 | | Total amount of fees paid to insurance company | USD $236 | | Other welfare benefits provided | ACCIDENTAL DEATH | | Welfare Benefit Premiums Paid to Carrier | USD $12,433 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| TRUSTMARK INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61425 ) |
| Policy contract number | 0365700000 |
| Policy instance | 8 |
| Insurance contract or identification number | 0365700000 | | Number of Individuals Covered | 595 | | Insurance policy start date | 2017-07-01 | | Insurance policy end date | 2017-10-01 | | Total amount of commissions paid to insurance broker | USD $5,743 | | Other welfare benefits provided | ACCIDENT | | Welfare Benefit Premiums Paid to Carrier | USD $20,623 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| TRUSTMARK INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61425 ) |
| Policy contract number | 0365700000 |
| Policy instance | 9 |
| Insurance contract or identification number | 0365700000 | | Number of Individuals Covered | 271 | | Insurance policy start date | 2017-07-01 | | Insurance policy end date | 2017-10-01 | | Total amount of commissions paid to insurance broker | USD $7,390 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $25,135 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| AMERICAN GENERAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60488 ) |
| Policy contract number | 6368V5 |
| Policy instance | 10 |
| Insurance contract or identification number | 6368V5 | | Number of Individuals Covered | 153 | | Insurance policy start date | 2017-07-01 | | Insurance policy end date | 2017-08-31 | | Total amount of commissions paid to insurance broker | USD $977 | | Health Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $6,513 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 900214 |
| Policy instance | 11 |
| Insurance contract or identification number | 900214 | | Number of Individuals Covered | 500 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-06-30 | | Total amount of commissions paid to insurance broker | USD $16,914 | | Total amount of fees paid to insurance company | USD $8,780 | | Other welfare benefits provided | ACCIDENT AND CRITICAL ILLNESS | | Welfare Benefit Premiums Paid to Carrier | USD $138,298 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| TRUSTMARK INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61425 ) |
| Policy contract number | 0365700000 |
| Policy instance | 8 |
| Insurance contract or identification number | 0365700000 | | Number of Individuals Covered | 743 | | Insurance policy start date | 2015-07-01 | | Insurance policy end date | 2016-06-30 | | Total amount of commissions paid to insurance broker | USD $86,191 | | Other welfare benefits provided | ACCIDENT | | Welfare Benefit Premiums Paid to Carrier | USD $133,628 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $62,974 | | Insurance broker organization code? | 3 | | Insurance broker name | LOCKTON COMPANIES, LLC |
|
| HUMANA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 73288 ) |
| Policy contract number | 709447 |
| Policy instance | 11 |
| Insurance contract or identification number | 709447 | | Number of Individuals Covered | 38 | | Insurance policy start date | 2016-04-01 | | Insurance policy end date | 2016-06-30 | | Total amount of commissions paid to insurance broker | USD $2,574 | | Welfare Benefit Premiums Paid to Carrier | USD $17,995 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $858 | | Insurance broker organization code? | 3 | | Insurance broker name | LOCKTON COMPANIES, LLC |
|
| TRUSTMARK INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61425 ) |
| Policy contract number | 0365700000 |
| Policy instance | 7 |
| Insurance contract or identification number | 0365700000 | | Number of Individuals Covered | 458 | | Insurance policy start date | 2015-07-01 | | Insurance policy end date | 2016-06-30 | | Total amount of commissions paid to insurance broker | USD $138,925 | | Other welfare benefits provided | CANCER/CRITICAL ILLNESS | | Welfare Benefit Premiums Paid to Carrier | USD $199,553 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $101,290 | | Insurance broker organization code? | 3 | | Insurance broker name | LOCKTON COMPANIES, LLC |
|
| TRUSTMARK INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61425 ) |
| Policy contract number | 0365700000 |
| Policy instance | 9 |
| Insurance contract or identification number | 0365700000 | | Number of Individuals Covered | 317 | | Insurance policy start date | 2015-07-01 | | Insurance policy end date | 2016-06-30 | | Total amount of commissions paid to insurance broker | USD $110,318 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $138,279 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $79,812 | | Insurance broker organization code? | 3 | | Insurance broker name | LOCKTON COMPANIES, LLC |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | OK 963868 |
| Policy instance | 6 |
| Insurance contract or identification number | OK 963868 | | Number of Individuals Covered | 300 | | Insurance policy start date | 2015-07-01 | | Insurance policy end date | 2016-06-30 | | Total amount of commissions paid to insurance broker | USD $2,676 | | Total amount of fees paid to insurance company | USD $321 | | Other welfare benefits provided | VOLUNTARY AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $11,893 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,676 | | Amount paid for insurance broker fees | 321 | | Additional information about fees paid to insurance broker | OVERRIDE | | Insurance broker organization code? | 3 | | Insurance broker name | LOCKTON COMPANIES, LLC |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | OK 961096 |
| Policy instance | 5 |
| Insurance contract or identification number | OK 961096 | | Number of Individuals Covered | 1136 | | Insurance policy start date | 2015-07-01 | | Insurance policy end date | 2016-06-30 | | Total amount of fees paid to insurance company | USD $284 | | Other welfare benefits provided | ACCIDENTAL DEATH | | Welfare Benefit Premiums Paid to Carrier | USD $10,600 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 284 | | Additional information about fees paid to insurance broker | OVERRIDE | | Insurance broker organization code? | 3 | | Insurance broker name | LOCKTON COMPANIES, LLC |
|
| AMERICAN GENERAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60488 ) |
| Policy contract number | 6368V5 |
| Policy instance | 4 |
| Insurance contract or identification number | 6368V5 | | Number of Individuals Covered | 191 | | Insurance policy start date | 2015-07-01 | | Insurance policy end date | 2016-06-30 | | Total amount of commissions paid to insurance broker | USD $3,563 | | Health Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $23,757 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,423 | | Insurance broker organization code? | 3 | | Insurance broker name | DAVID WIGGINS |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | LK 960866 |
| Policy instance | 3 |
| Insurance contract or identification number | LK 960866 | | Number of Individuals Covered | 275 | | Insurance policy start date | 2015-07-01 | | Insurance policy end date | 2016-06-30 | | Total amount of fees paid to insurance company | USD $956 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $36,394 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 956 | | Additional information about fees paid to insurance broker | OVERRIDE | | Insurance broker organization code? | 3 | | Insurance broker name | LOCKTON COMPANIES, LLC |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | FLX962243 |
| Policy instance | 2 |
| Insurance contract or identification number | FLX962243 | | Number of Individuals Covered | 515 | | Insurance policy start date | 2015-07-01 | | Insurance policy end date | 2016-06-30 | | Total amount of commissions paid to insurance broker | USD $47,529 | | Total amount of fees paid to insurance company | USD $4,146 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $211,240 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $47,529 | | Amount paid for insurance broker fees | 4146 | | Additional information about fees paid to insurance broker | OVERRIDE | | Insurance broker organization code? | 3 | | Insurance broker name | LOCKTON COMPANIES, LLC |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | FLX961043 |
| Policy instance | 1 |
| Insurance contract or identification number | FLX961043 | | Number of Individuals Covered | 1961 | | Insurance policy start date | 2015-07-01 | | Insurance policy end date | 2016-06-30 | | Total amount of fees paid to insurance company | USD $1,272 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $51,544 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 1272 | | Additional information about fees paid to insurance broker | OVERRIDE | | Insurance broker organization code? | 3 | | Insurance broker name | LOCKTON COMPANIES, LLC |
|
| DELTA DENTAL OF KANSAS (National Association of Insurance Commissioners NAIC id number: 54615 ) |
| Policy contract number | 50753-000-00001 |
| Policy instance | 10 |
| Insurance contract or identification number | 50753-000-00001 | | Number of Individuals Covered | 23 | | Insurance policy start date | 2016-04-01 | | Insurance policy end date | 2016-06-30 | | Total amount of commissions paid to insurance broker | USD $137 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $2,582 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $137 | | Insurance broker organization code? | 3 | | Insurance broker name | THE MILLER GROUP |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | FLX961043 |
| Policy instance | 1 |
| Insurance contract or identification number | FLX961043 | | Number of Individuals Covered | 1916 | | Insurance policy start date | 2014-07-01 | | Insurance policy end date | 2015-06-30 | | Total amount of commissions paid to insurance broker | USD $1,960 | | Total amount of fees paid to insurance company | USD $1,374 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $74,682 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,960 | | Amount paid for insurance broker fees | 1374 | | Additional information about fees paid to insurance broker | OVERRIDE | | Insurance broker organization code? | 3 | | Insurance broker name | HAYS COMPANIES |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | FLX962243 |
| Policy instance | 2 |
| Insurance contract or identification number | FLX962243 | | Number of Individuals Covered | 337 | | Insurance policy start date | 2014-07-01 | | Insurance policy end date | 2015-06-30 | | Total amount of commissions paid to insurance broker | USD $43,791 | | Total amount of fees paid to insurance company | USD $3,493 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $194,627 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $22,825 | | Amount paid for insurance broker fees | 3493 | | Additional information about fees paid to insurance broker | OVERRIDE | | Insurance broker organization code? | 3 | | Insurance broker name | LOCKTON COMPANIES, LLC |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | LK 960866 |
| Policy instance | 3 |
| Insurance contract or identification number | LK 960866 | | Number of Individuals Covered | 293 | | Insurance policy start date | 2014-07-01 | | Insurance policy end date | 2015-06-30 | | Total amount of commissions paid to insurance broker | USD $1,277 | | Total amount of fees paid to insurance company | USD $892 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $46,776 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,277 | | Amount paid for insurance broker fees | 892 | | Additional information about fees paid to insurance broker | OVERRIDE | | Insurance broker organization code? | 3 | | Insurance broker name | HAYS COMPANIES |
|
| TRUSTMARK INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61425 ) |
| Policy contract number | 0365700000 |
| Policy instance | 8 |
| Insurance contract or identification number | 0365700000 | | Number of Individuals Covered | 731 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-06-30 | | Total amount of commissions paid to insurance broker | USD $28,043 | | Other welfare benefits provided | ACCIDENT | | Welfare Benefit Premiums Paid to Carrier | USD $40,069 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $17,628 | | Insurance broker organization code? | 3 | | Insurance broker name | LOCKTON COMPANIES, LLC |
|
| TRUSTMARK INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61425 ) |
| Policy contract number | 0365700000 |
| Policy instance | 9 |
| Insurance contract or identification number | 0365700000 | | Number of Individuals Covered | 311 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-06-30 | | Total amount of commissions paid to insurance broker | USD $43,336 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $41,308 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $26,827 | | Insurance broker organization code? | 3 | | Insurance broker name | LOCKTON COMPANIES, LLC |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | OK 963868 |
| Policy instance | 6 |
| Insurance contract or identification number | OK 963868 | | Number of Individuals Covered | 4 | | Insurance policy start date | 2014-07-01 | | Insurance policy end date | 2015-06-30 | | Total amount of commissions paid to insurance broker | USD $3,243 | | Total amount of fees paid to insurance company | USD $287 | | Other welfare benefits provided | VOLUNTARY AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $15,340 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,664 | | Amount paid for insurance broker fees | 287 | | Additional information about fees paid to insurance broker | OVERRIDE | | Insurance broker organization code? | 3 | | Insurance broker name | LOCKTON COMPANIES, LLC |
|
| TRUSTMARK INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61425 ) |
| Policy contract number | 0365700000 |
| Policy instance | 7 |
| Insurance contract or identification number | 0365700000 | | Number of Individuals Covered | 482 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-06-30 | | Total amount of commissions paid to insurance broker | USD $43,161 | | Other welfare benefits provided | CANCER/CRITICAL ILLNESS | | Welfare Benefit Premiums Paid to Carrier | USD $57,548 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $27,048 | | Insurance broker organization code? | 3 | | Insurance broker name | LOCKTON COMPANIES, LLC |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | OK 961096 |
| Policy instance | 5 |
| Insurance contract or identification number | OK 961096 | | Number of Individuals Covered | 313 | | Insurance policy start date | 2014-07-01 | | Insurance policy end date | 2015-06-30 | | Total amount of commissions paid to insurance broker | USD $1,200 | | Total amount of fees paid to insurance company | USD $210 | | Other welfare benefits provided | ACCIDENTAL DEATH | | Welfare Benefit Premiums Paid to Carrier | USD $11,449 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,200 | | Amount paid for insurance broker fees | 210 | | Additional information about fees paid to insurance broker | OVERRIDE | | Insurance broker organization code? | 3 | | Insurance broker name | HAYS COMPANIES |
|
| AMERICAN GENERAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60488 ) |
| Policy contract number | 6368V5 |
| Policy instance | 4 |
| Insurance contract or identification number | 6368V5 | | Number of Individuals Covered | 305 | | Insurance policy start date | 2014-07-01 | | Insurance policy end date | 2015-06-30 | | Total amount of commissions paid to insurance broker | USD $8,830 | | Health Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $2,143 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,444 | | Insurance broker organization code? | 3 | | Insurance broker name | DAVID EVANS |
|
| AMERICAN GENERAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60488 ) |
| Policy contract number | 0MM270 |
| Policy instance | 9 |
| Insurance contract or identification number | 0MM270 | | Number of Individuals Covered | 289 | | Insurance policy start date | 2013-07-01 | | Insurance policy end date | 2014-06-30 | | Total amount of commissions paid to insurance broker | USD $9,192 | | 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 | Yes | | 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 $111,783 | | Commission paid to Insurance Broker | USD $4,711 | | Insurance broker organization code? | 3 | | Insurance broker name | THE HAYS GROUP, INC. |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | LK960866 |
| Policy instance | 7 |
| Insurance contract or identification number | LK960866 | | Number of Individuals Covered | 312 | | Insurance policy start date | 2013-07-01 | | Insurance policy end date | 2014-06-30 | | Total amount of commissions paid to insurance broker | USD $2,105 | | Total amount of fees paid to insurance company | USD $922 | | 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 | 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 $42,108 | | Commission paid to Insurance Broker | USD $2,105 | | Amount paid for insurance broker fees | 922 | | Additional information about fees paid to insurance broker | OVERRIDE | | Insurance broker organization code? | 3 | | Insurance broker name | THE HAYS GROUP, INC. |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | FLX961043 |
| Policy instance | 5 |
| Insurance contract or identification number | FLX961043 | | Number of Individuals Covered | 1236 | | Insurance policy start date | 2013-07-01 | | Insurance policy end date | 2014-06-30 | | Total amount of commissions paid to insurance broker | USD $3,224 | | Total amount of fees paid to insurance company | USD $1,555 | | 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 | 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 $64,481 | | Commission paid to Insurance Broker | USD $3,224 | | Amount paid for insurance broker fees | 1555 | | Additional information about fees paid to insurance broker | OVERRIDE | | Insurance broker organization code? | 3 | | Insurance broker name | THE HAYS GROUP, INC. |
|
| AMERICAN GENERAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60488 ) |
| Policy contract number | 6368V5 |
| Policy instance | 6 |
| Insurance contract or identification number | 6368V5 | | Number of Individuals Covered | 258 | | Insurance policy start date | 2013-07-01 | | Insurance policy end date | 2014-06-30 | | Total amount of commissions paid to insurance broker | USD $9,447 | | 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 | 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 | 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 $59,385 | | Commission paid to Insurance Broker | USD $5,836 | | Insurance broker organization code? | 3 | | Insurance broker name | DAVID L. EVANS |
|
| TRANSAMERICA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 86231 ) |
| Policy contract number | PF003175-04 |
| Policy instance | 3 |
| Insurance contract or identification number | PF003175-04 | | Number of Individuals Covered | 1267 | | Insurance policy start date | 2013-07-01 | | Insurance policy end date | 2014-06-30 | | 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? | 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 $233,120 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | FLX 962243 |
| Policy instance | 2 |
| Insurance contract or identification number | FLX 962243 | | Number of Individuals Covered | 389 | | Insurance policy start date | 2013-07-01 | | Insurance policy end date | 2014-06-30 | | Total amount of commissions paid to insurance broker | USD $36,514 | | Total amount of fees paid to insurance company | USD $3,545 | | 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 | 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 $162,283 | | Commission paid to Insurance Broker | USD $36,514 | | Amount paid for insurance broker fees | 3545 | | Additional information about fees paid to insurance broker | OVERRIDE | | Insurance broker organization code? | 3 | | Insurance broker name | THE HAYS GROUP, INC. |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | OK963868 |
| Policy instance | 1 |
| Insurance contract or identification number | OK963868 | | Number of Individuals Covered | 350 | | Insurance policy start date | 2013-07-01 | | Insurance policy end date | 2014-06-30 | | Total amount of commissions paid to insurance broker | USD $3,359 | | Total amount of fees paid to insurance company | USD $313 | | 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 | VOLUNTARY 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 $16,796 | | Commission paid to Insurance Broker | USD $3,359 | | Amount paid for insurance broker fees | 313 | | Additional information about fees paid to insurance broker | OVERRIDE | | Insurance broker organization code? | 3 | | Insurance broker name | THE HAYS GROUP, INC. |
|
| AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 ) |
| Policy contract number | V1321 |
| Policy instance | 8 |
| Insurance contract or identification number | V1321 | | Number of Individuals Covered | 665 | | Insurance policy start date | 2013-07-01 | | Insurance policy end date | 2014-06-30 | | Total amount of commissions paid to insurance broker | USD $53,628 | | 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 | 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 $258,372 | | Commission paid to Insurance Broker | USD $26,814 | | Insurance broker organization code? | 3 | | Insurance broker name | THE HAYS GROUP, INC. |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | OK961096 |
| Policy instance | 4 |
| Insurance contract or identification number | OK961096 | | Number of Individuals Covered | 1236 | | Insurance policy start date | 2013-07-01 | | Insurance policy end date | 2014-06-30 | | Total amount of commissions paid to insurance broker | USD $1,354 | | Total amount of fees paid to insurance company | USD $214 | | 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 | 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 $6,769 | | Commission paid to Insurance Broker | USD $1,354 | | Amount paid for insurance broker fees | 214 | | Additional information about fees paid to insurance broker | OVERRIDE | | Insurance broker organization code? | 3 | | Insurance broker name | THE HAYS GROUP, INC. |
|
| AMERICAN GENERAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60488 ) |
| Policy contract number | 6368V5 |
| Policy instance | 8 |
| Insurance contract or identification number | 6368V5 | | Number of Individuals Covered | 636 | | Insurance policy start date | 2012-07-01 | | Insurance policy end date | 2013-06-30 | | Total amount of commissions paid to insurance broker | USD $32,425 | | 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 | 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 | 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 $208,051 | | Commission paid to Insurance Broker | USD $18,939 | | Insurance broker organization code? | 3 | | Insurance broker name | DAVID L. EVANS |
|
| COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 ) |
| Policy contract number | 7976301/7976319 |
| Policy instance | 10 |
| Insurance contract or identification number | 7976301/7976319 | | Number of Individuals Covered | 370 | | Insurance policy start date | 2012-04-01 | | Insurance policy end date | 2013-03-31 | | Total amount of commissions paid to insurance broker | USD $1,129 | | Total amount of fees paid to insurance company | USD $210 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | 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 $20,010 | | Commission paid to Insurance Broker | USD $496 | | Amount paid for insurance broker fees | 43 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker organization code? | 3 | | Insurance broker name | TAMARA ANN BUSCHER |
|
| AMERICAN GENERAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60488 ) |
| Policy contract number | 0MM270 |
| Policy instance | 7 |
| Insurance contract or identification number | 0MM270 | | Number of Individuals Covered | 360 | | Insurance policy start date | 2012-07-01 | | Insurance policy end date | 2013-06-30 | | Total amount of commissions paid to insurance broker | USD $36,378 | | 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 | Yes | | 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 $146,916 | | Commission paid to Insurance Broker | USD $22,625 | | Insurance broker organization code? | 3 | | Insurance broker name | THE HAYS GROUP, INC. |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | OK963868 |
| Policy instance | 6 |
| Insurance contract or identification number | OK963868 | | Number of Individuals Covered | 394 | | Insurance policy start date | 2012-07-01 | | Insurance policy end date | 2013-06-30 | | Total amount of commissions paid to insurance broker | USD $1,972 | | Total amount of fees paid to insurance company | USD $212 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 | VOLUNTARY 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 $13,146 | | Commission paid to Insurance Broker | USD $1,972 | | Amount paid for insurance broker fees | 212 | | Additional information about fees paid to insurance broker | OVERRIDE | | Insurance broker organization code? | 3 | | Insurance broker name | THE HAYS GROUP, INC. |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | LK960866 |
| Policy instance | 5 |
| Insurance contract or identification number | LK960866 | | Number of Individuals Covered | 336 | | Insurance policy start date | 2012-07-01 | | Insurance policy end date | 2013-06-30 | | Total amount of commissions paid to insurance broker | USD $3,662 | | Total amount of fees paid to insurance company | USD $672 | | 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 | 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 $44,893 | | Commission paid to Insurance Broker | USD $3,662 | | Amount paid for insurance broker fees | 672 | | Additional information about fees paid to insurance broker | OVERRIDE | | Insurance broker organization code? | 3 | | Insurance broker name | THE HAYS GROUP, INC. |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | FLX961043 |
| Policy instance | 4 |
| Insurance contract or identification number | FLX961043 | | Number of Individuals Covered | 1283 | | Insurance policy start date | 2012-07-01 | | Insurance policy end date | 2013-06-30 | | Total amount of commissions paid to insurance broker | USD $3,048 | | Total amount of fees paid to insurance company | USD $1,747 | | 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 | 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 $92,347 | | Commission paid to Insurance Broker | USD $3,048 | | Amount paid for insurance broker fees | 1747 | | Additional information about fees paid to insurance broker | OVERRIDE | | Insurance broker organization code? | 3 | | Insurance broker name | THE HAYS GROUP, INC. |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | OK961096 |
| Policy instance | 3 |
| Insurance contract or identification number | OK961096 | | Number of Individuals Covered | 1283 | | Insurance policy start date | 2012-07-01 | | Insurance policy end date | 2013-06-30 | | Total amount of commissions paid to insurance broker | USD $2,013 | | Total amount of fees paid to insurance company | USD $283 | | 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 | 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 $14,417 | | Commission paid to Insurance Broker | USD $2,013 | | Amount paid for insurance broker fees | 283 | | Additional information about fees paid to insurance broker | OVERRIDE | | Insurance broker organization code? | 3 | | Insurance broker name | THE HAYS GROUP, INC. |
|
| AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 ) |
| Policy contract number | V1321 |
| Policy instance | 9 |
| Insurance contract or identification number | V1321 | | Number of Individuals Covered | 510 | | Insurance policy start date | 2012-07-01 | | Insurance policy end date | 2013-06-30 | | Total amount of commissions paid to insurance broker | USD $34,972 | | 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 | 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 $228,389 | | Commission paid to Insurance Broker | USD $17,486 | | Insurance broker organization code? | 3 | | Insurance broker name | THE HAYS GROUP, INC. |
|
| TRANSAMERICA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 86231 ) |
| Policy contract number | PF003175-04 |
| Policy instance | 2 |
| Insurance contract or identification number | PF003175-04 | | Number of Individuals Covered | 1273 | | Insurance policy start date | 2012-07-01 | | Insurance policy end date | 2013-06-30 | | 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? | 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 $203,945 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | FLX 962243 |
| Policy instance | 1 |
| Insurance contract or identification number | FLX 962243 | | Number of Individuals Covered | 430 | | Insurance policy start date | 2012-07-01 | | Insurance policy end date | 2013-06-30 | | Total amount of commissions paid to insurance broker | USD $29,261 | | Total amount of fees paid to insurance company | USD $3,170 | | 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 | 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 $177,036 | | Commission paid to Insurance Broker | USD $29,261 | | Amount paid for insurance broker fees | 3170 | | Additional information about fees paid to insurance broker | OVERRIDE | | Insurance broker organization code? | 3 | | Insurance broker name | THE HAYS GROUP, INC. |
|
| COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 ) |
| Policy contract number | 7976301/7976319 |
| Policy instance | 10 |
| Insurance contract or identification number | 7976301/7976319 | | Number of Individuals Covered | 392 | | Insurance policy start date | 2011-04-01 | | Insurance policy end date | 2012-03-31 | | Total amount of commissions paid to insurance broker | USD $49,748 | | Total amount of fees paid to insurance company | USD $7,713 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | 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 $253,700 |
|
| AMERICAN GENERAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60488 ) |
| Policy contract number | 0MM270 |
| Policy instance | 9 |
| Insurance contract or identification number | 0MM270 | | Number of Individuals Covered | 360 | | Insurance policy start date | 2011-07-01 | | Insurance policy end date | 2012-06-30 | | Total amount of commissions paid to insurance broker | USD $69,627 | | 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 | Yes | | 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 $135,498 |
|
| CHARTIS (National Association of Insurance Commissioners NAIC id number: 66842 ) |
| Policy contract number | 6368V5 |
| Policy instance | 7 |
| Insurance contract or identification number | 6368V5 | | Number of Individuals Covered | 660 | | Insurance policy start date | 2011-04-01 | | Insurance policy end date | 2012-03-31 | | Total amount of commissions paid to insurance broker | USD $125,500 | | 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 | 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 $179,077 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | FLX961043 |
| Policy instance | 6 |
| Insurance contract or identification number | FLX961043 | | Number of Individuals Covered | 1319 | | Insurance policy start date | 2011-07-01 | | Insurance policy end date | 2012-06-30 | | Total amount of commissions paid to insurance broker | USD $3,910 | | Total amount of fees paid to insurance company | USD $1,892 | | 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 | 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 $103,144 |
|
| TRANSAMERICA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 86231 ) |
| Policy contract number | PF003175-04 |
| Policy instance | 5 |
| Insurance contract or identification number | PF003175-04 | | Number of Individuals Covered | 1322 | | Insurance policy start date | 2011-07-01 | | Insurance policy end date | 2012-06-30 | | 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? | 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 $192,907 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | OK961096 |
| Policy instance | 4 |
| Insurance contract or identification number | OK961096 | | Number of Individuals Covered | 1319 | | Insurance policy start date | 2011-07-01 | | Insurance policy end date | 2012-06-30 | | Total amount of commissions paid to insurance broker | USD $1,969 | | Total amount of fees paid to insurance company | USD $477 | | 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 | 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 $24,073 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | OK963868 |
| Policy instance | 3 |
| Insurance contract or identification number | OK963868 | | Number of Individuals Covered | 434 | | Insurance policy start date | 2012-04-01 | | Insurance policy end date | 2012-06-30 | | Total amount of commissions paid to insurance broker | USD $582 | | 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 | | Other welfare benefits provided | VOLUNTARY 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 $3,880 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | LK960866 |
| Policy instance | 2 |
| Insurance contract or identification number | LK960866 | | Number of Individuals Covered | 305 | | Insurance policy start date | 2011-07-01 | | Insurance policy end date | 2012-06-30 | | Total amount of commissions paid to insurance broker | USD $3,582 | | Total amount of fees paid to insurance company | USD $887 | | 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 | 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 $39,799 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | FLX 962243 |
| Policy instance | 1 |
| Insurance contract or identification number | FLX 962243 | | Number of Individuals Covered | 468 | | Insurance policy start date | 2011-07-01 | | Insurance policy end date | 2012-06-30 | | Total amount of commissions paid to insurance broker | USD $29,044 | | Total amount of fees paid to insurance company | USD $3,601 | | 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 | 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 $193,628 |
|
| AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 ) |
| Policy contract number | V1321 |
| Policy instance | 8 |
| Insurance contract or identification number | V1321 | | Number of Individuals Covered | 590 | | Insurance policy start date | 2011-07-01 | | Insurance policy end date | 2012-06-30 | | Total amount of commissions paid to insurance broker | USD $155,654 | | 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 | 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 $184,439 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | FLX 962243 |
| Policy instance | 6 |
| Insurance contract or identification number | FLX 962243 | | Number of Individuals Covered | 501 | | Insurance policy start date | 2010-07-01 | | Insurance policy end date | 2011-06-30 | | Total amount of commissions paid to insurance broker | USD $31,571 | | Total amount of fees paid to insurance company | USD $2,054 | | 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 | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | VOLUNTARY 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 $213,987 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | FLX961043 |
| Policy instance | 5 |
| Insurance contract or identification number | FLX961043 | | Number of Individuals Covered | 1423 | | Insurance policy start date | 2010-07-01 | | Insurance policy end date | 2011-06-30 | | Total amount of commissions paid to insurance broker | USD $2,958 | | Total amount of fees paid to insurance company | USD $1,124 | | 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 | 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 $111,139 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | OK961096 |
| Policy instance | 4 |
| Insurance contract or identification number | OK961096 | | Number of Individuals Covered | 1423 | | Insurance policy start date | 2010-07-01 | | Insurance policy end date | 2011-06-30 | | Total amount of commissions paid to insurance broker | USD $4,496 | | Total amount of fees paid to insurance company | USD $166 | | 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 | 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 $24,107 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | LK960866 |
| Policy instance | 3 |
| Insurance contract or identification number | LK960866 | | Number of Individuals Covered | 312 | | Insurance policy start date | 2010-07-01 | | Insurance policy end date | 2011-06-30 | | Total amount of commissions paid to insurance broker | USD $3,187 | | Total amount of fees paid to insurance company | USD $548 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating 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 $54,780 |
|
| TRANSAMERICA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 86231 ) |
| Policy contract number | PF003175-04 |
| Policy instance | 2 |
| Insurance contract or identification number | PF003175-04 | | Number of Individuals Covered | 1440 | | Insurance policy start date | 2010-07-01 | | Insurance policy end date | 2011-06-30 | | 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? | 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 $268,780 |
|
| COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 ) |
| Policy contract number | 7976301/7976319 |
| Policy instance | 1 |
| Insurance contract or identification number | 7976301/7976319 | | Number of Individuals Covered | 1189 | | Insurance policy start date | 2010-04-01 | | Insurance policy end date | 2011-03-31 | | Total amount of commissions paid to insurance broker | USD $161,012 | | Total amount of fees paid to insurance company | USD $28,064 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | 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 $888,613 |
|
