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FAVORITE HEALTHCARE STAFFING, INC. EMPLOYEE BENEFITS PLAN 401k Plan overview

Plan NameFAVORITE HEALTHCARE STAFFING, INC. EMPLOYEE BENEFITS PLAN
Plan identification number 501

FAVORITE HEALTHCARE STAFFING, INC. EMPLOYEE BENEFITS PLAN Benefits

401k Plan TypeWelfare Benefit
Plan Features/Benefits
  • Health (other than dental or vision)
  • Life insurance
  • Dental
  • Vision
  • Temporary disability (accident and sickness)
  • Long-term disability cover
  • Death benefits (include travel accident but not life insurance)
  • Other welfare benefit cover

401k Sponsoring company profile

FAVORITE HEALTHCARE STAFFING, INC. has sponsored the creation of one or more 401k plans.

Company Name:FAVORITE HEALTHCARE STAFFING, INC.
Employer identification number (EIN):480985059
NAIC Classification:623000
NAIC Description: Nursing and Residential Care Facilities

Additional information about FAVORITE HEALTHCARE STAFFING, INC.

Jurisdiction of Incorporation: State of Delaware Division of Corporations
Incorporation Date:
Company Identification Number: 2157550

More information about FAVORITE HEALTHCARE STAFFING, INC.

Form 5500 Filing Information

Submission information for form 5500 for 401k plan FAVORITE HEALTHCARE STAFFING, INC. EMPLOYEE BENEFITS PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5012020-01-01MEGAN BARNES2021-08-02 MEGAN BARNES2021-08-02
5012019-01-01
5012018-01-01CHRISTOPHER BRINK
5012017-01-01CHRISTOPHER BRINK
5012016-01-01CHRISTOPHER BRINK
5012015-01-01CHRISTOPHER BRINK
5012014-01-01CHRISTOPHER BRINK
5012013-01-01CHRISTOPHER BRINK
5012012-01-01CHRISTOPHER BRINK
5012011-01-01CHRISTOPHER BRINK
5012010-01-01CHRISTOPHER BRINK
5012009-01-01CHRISTOPHER BRINK

Plan Statistics for FAVORITE HEALTHCARE STAFFING, INC. EMPLOYEE BENEFITS PLAN

401k plan membership statisitcs for FAVORITE HEALTHCARE STAFFING, INC. EMPLOYEE BENEFITS PLAN

Measure Date Value
2020: FAVORITE HEALTHCARE STAFFING, INC. EMPLOYEE BENEFITS PLAN 2020 401k membership
Total participants, beginning-of-year2020-01-01342
Total number of active participants reported on line 7a of the Form 55002020-01-01412
Number of retired or separated participants receiving benefits2020-01-0115
Number of other retired or separated participants entitled to future benefits2020-01-010
Total of all active and inactive participants2020-01-01427
2019: FAVORITE HEALTHCARE STAFFING, INC. EMPLOYEE BENEFITS PLAN 2019 401k membership
Total participants, beginning-of-year2019-01-01289
Total number of active participants reported on line 7a of the Form 55002019-01-01258
Number of retired or separated participants receiving benefits2019-01-015
Number of other retired or separated participants entitled to future benefits2019-01-0179
Total of all active and inactive participants2019-01-01342
2018: FAVORITE HEALTHCARE STAFFING, INC. EMPLOYEE BENEFITS PLAN 2018 401k membership
Total participants, beginning-of-year2018-01-01284
Total number of active participants reported on line 7a of the Form 55002018-01-01335
Number of retired or separated participants receiving benefits2018-01-010
Number of other retired or separated participants entitled to future benefits2018-01-010
Total of all active and inactive participants2018-01-01335
2017: FAVORITE HEALTHCARE STAFFING, INC. EMPLOYEE BENEFITS PLAN 2017 401k membership
Total participants, beginning-of-year2017-01-01247
Total number of active participants reported on line 7a of the Form 55002017-01-01247
Number of retired or separated participants receiving benefits2017-01-010
Number of other retired or separated participants entitled to future benefits2017-01-010
Total of all active and inactive participants2017-01-01247
2016: FAVORITE HEALTHCARE STAFFING, INC. EMPLOYEE BENEFITS PLAN 2016 401k membership
Total participants, beginning-of-year2016-01-01221
Total number of active participants reported on line 7a of the Form 55002016-01-01247
Number of retired or separated participants receiving benefits2016-01-010
Number of other retired or separated participants entitled to future benefits2016-01-010
Total of all active and inactive participants2016-01-01247
2015: FAVORITE HEALTHCARE STAFFING, INC. EMPLOYEE BENEFITS PLAN 2015 401k membership
Total participants, beginning-of-year2015-01-01292
Total number of active participants reported on line 7a of the Form 55002015-01-01303
Number of retired or separated participants receiving benefits2015-01-010
Number of other retired or separated participants entitled to future benefits2015-01-010
Total of all active and inactive participants2015-01-01303
2014: FAVORITE HEALTHCARE STAFFING, INC. EMPLOYEE BENEFITS PLAN 2014 401k membership
Total participants, beginning-of-year2014-01-01276
Total number of active participants reported on line 7a of the Form 55002014-01-01292
Number of retired or separated participants receiving benefits2014-01-010
Number of other retired or separated participants entitled to future benefits2014-01-010
Total of all active and inactive participants2014-01-01292
2013: FAVORITE HEALTHCARE STAFFING, INC. EMPLOYEE BENEFITS PLAN 2013 401k membership
Total participants, beginning-of-year2013-01-01220
Total number of active participants reported on line 7a of the Form 55002013-01-01224
Total of all active and inactive participants2013-01-01224
2012: FAVORITE HEALTHCARE STAFFING, INC. EMPLOYEE BENEFITS PLAN 2012 401k membership
Total participants, beginning-of-year2012-01-01215
Total number of active participants reported on line 7a of the Form 55002012-01-01220
Total of all active and inactive participants2012-01-01220
2011: FAVORITE HEALTHCARE STAFFING, INC. EMPLOYEE BENEFITS PLAN 2011 401k membership
Total participants, beginning-of-year2011-01-01224
Total number of active participants reported on line 7a of the Form 55002011-01-01215
Total of all active and inactive participants2011-01-01215
2010: FAVORITE HEALTHCARE STAFFING, INC. EMPLOYEE BENEFITS PLAN 2010 401k membership
Total participants, beginning-of-year2010-01-01220
Total number of active participants reported on line 7a of the Form 55002010-01-01224
Total of all active and inactive participants2010-01-01224
2009: FAVORITE HEALTHCARE STAFFING, INC. EMPLOYEE BENEFITS PLAN 2009 401k membership
Total participants, beginning-of-year2009-01-01219
Total number of active participants reported on line 7a of the Form 55002009-01-01220
Total of all active and inactive participants2009-01-01220
Total participants2009-01-01220

Form 5500 Responses for FAVORITE HEALTHCARE STAFFING, INC. EMPLOYEE BENEFITS PLAN

2020: FAVORITE HEALTHCARE STAFFING, INC. EMPLOYEE BENEFITS PLAN 2020 form 5500 responses
2020-01-01Type of plan entitySingle employer plan
2020-01-01Submission has been amendedNo
2020-01-01This submission is the final filingNo
2020-01-01This return/report is a short plan year return/report (less than 12 months)No
2020-01-01Plan is a collectively bargained planNo
2020-01-01Plan funding arrangement – InsuranceYes
2020-01-01Plan funding arrangement – General assets of the sponsorYes
2020-01-01Plan benefit arrangement – InsuranceYes
2020-01-01Plan benefit arrangement – General assets of the sponsorYes
2019: FAVORITE HEALTHCARE STAFFING, INC. EMPLOYEE BENEFITS PLAN 2019 form 5500 responses
2019-01-01Type of plan entitySingle employer plan
2019-01-01Submission has been amendedNo
2019-01-01This submission is the final filingNo
2019-01-01This return/report is a short plan year return/report (less than 12 months)No
2019-01-01Plan is a collectively bargained planNo
2019-01-01Plan funding arrangement – InsuranceYes
2019-01-01Plan benefit arrangement – InsuranceYes
2018: FAVORITE HEALTHCARE STAFFING, INC. EMPLOYEE BENEFITS PLAN 2018 form 5500 responses
2018-01-01Type of plan entitySingle employer plan
2018-01-01Submission has been amendedNo
2018-01-01This submission is the final filingNo
2018-01-01This return/report is a short plan year return/report (less than 12 months)No
2018-01-01Plan is a collectively bargained planNo
2018-01-01Plan funding arrangement – InsuranceYes
2018-01-01Plan funding arrangement – General assets of the sponsorYes
2018-01-01Plan benefit arrangement – InsuranceYes
2018-01-01Plan benefit arrangement – General assets of the sponsorYes
2017: FAVORITE HEALTHCARE STAFFING, INC. EMPLOYEE BENEFITS PLAN 2017 form 5500 responses
2017-01-01Type of plan entitySingle employer plan
2017-01-01Submission has been amendedNo
2017-01-01This submission is the final filingNo
2017-01-01This return/report is a short plan year return/report (less than 12 months)No
2017-01-01Plan is a collectively bargained planNo
2017-01-01Plan funding arrangement – InsuranceYes
2017-01-01Plan funding arrangement – General assets of the sponsorYes
2017-01-01Plan benefit arrangement – InsuranceYes
2017-01-01Plan benefit arrangement – General assets of the sponsorYes
2016: FAVORITE HEALTHCARE STAFFING, INC. EMPLOYEE BENEFITS PLAN 2016 form 5500 responses
2016-01-01Type of plan entitySingle employer plan
2016-01-01Submission has been amendedNo
2016-01-01This submission is the final filingNo
2016-01-01This return/report is a short plan year return/report (less than 12 months)No
2016-01-01Plan is a collectively bargained planNo
2016-01-01Plan funding arrangement – InsuranceYes
2016-01-01Plan funding arrangement – General assets of the sponsorYes
2016-01-01Plan benefit arrangement – InsuranceYes
2016-01-01Plan benefit arrangement – General assets of the sponsorYes
2015: FAVORITE HEALTHCARE STAFFING, INC. EMPLOYEE BENEFITS PLAN 2015 form 5500 responses
2015-01-01Type of plan entitySingle employer plan
2015-01-01Submission has been amendedNo
2015-01-01This submission is the final filingNo
2015-01-01This return/report is a short plan year return/report (less than 12 months)No
2015-01-01Plan is a collectively bargained planNo
2015-01-01Plan funding arrangement – InsuranceYes
2015-01-01Plan funding arrangement – General assets of the sponsorYes
2015-01-01Plan benefit arrangement – InsuranceYes
2015-01-01Plan benefit arrangement – General assets of the sponsorYes
2014: FAVORITE HEALTHCARE STAFFING, INC. EMPLOYEE BENEFITS PLAN 2014 form 5500 responses
2014-01-01Type of plan entitySingle employer plan
2014-01-01Submission has been amendedNo
2014-01-01This submission is the final filingNo
2014-01-01This return/report is a short plan year return/report (less than 12 months)No
2014-01-01Plan is a collectively bargained planNo
2014-01-01Plan funding arrangement – InsuranceYes
2014-01-01Plan funding arrangement – General assets of the sponsorYes
2014-01-01Plan benefit arrangement – InsuranceYes
2014-01-01Plan benefit arrangement – General assets of the sponsorYes
2013: FAVORITE HEALTHCARE STAFFING, INC. EMPLOYEE BENEFITS PLAN 2013 form 5500 responses
2013-01-01Type of plan entitySingle employer plan
2013-01-01Plan funding arrangement – InsuranceYes
2013-01-01Plan benefit arrangement – InsuranceYes
2012: FAVORITE HEALTHCARE STAFFING, INC. EMPLOYEE BENEFITS PLAN 2012 form 5500 responses
2012-01-01Type of plan entitySingle employer plan
2012-01-01Plan funding arrangement – InsuranceYes
2012-01-01Plan benefit arrangement – InsuranceYes
2011: FAVORITE HEALTHCARE STAFFING, INC. EMPLOYEE BENEFITS PLAN 2011 form 5500 responses
2011-01-01Type of plan entitySingle employer plan
2011-01-01Plan funding arrangement – InsuranceYes
2011-01-01Plan benefit arrangement – InsuranceYes
2010: FAVORITE HEALTHCARE STAFFING, INC. EMPLOYEE BENEFITS PLAN 2010 form 5500 responses
2010-01-01Type of plan entitySingle employer plan
2010-01-01Plan funding arrangement – InsuranceYes
2010-01-01Plan benefit arrangement – InsuranceYes
2009: FAVORITE HEALTHCARE STAFFING, INC. EMPLOYEE BENEFITS PLAN 2009 form 5500 responses
2009-01-01First time form 5500 has been submittedYes
2009-01-01Submission has been amendedNo
2009-01-01This submission is the final filingNo
2009-01-01This return/report is a short plan year return/report (less than 12 months)No
2009-01-01Plan is a collectively bargained planNo
2009-01-01Plan funding arrangement – InsuranceYes
2009-01-01Plan benefit arrangement – InsuranceYes

Insurance Providers Used on plan

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number400001000 23411
Policy instance 4
Insurance contract or identification number400001000 23411
Number of Individuals Covered113
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $6,448
Total amount of fees paid to insurance companyUSD $1,768
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $42,985
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,348
Insurance broker organization code?3
Amount paid for insurance broker fees788
Additional information about fees paid to insurance brokerBROKER BONUS
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number10236642
Policy instance 3
Insurance contract or identification number10236642
Number of Individuals Covered412
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $1,645
Total amount of fees paid to insurance companyUSD $595
Life Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $15,501
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,014
Insurance broker organization code?3
Amount paid for insurance broker fees261
Additional information about fees paid to insurance brokerBROKER BONUS
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number0109007
Policy instance 2
Insurance contract or identification number0109007
Number of Individuals Covered902
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $145,193
Total amount of fees paid to insurance companyUSD $40,997
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $5,206,290
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $93,621
Insurance broker organization code?3
Amount paid for insurance broker fees40997
Additional information about fees paid to insurance brokerPPP SPECIALTY NEW BUSINESS RISK; PREMIER PRODUCER PROGRAM - MEDICAL NEW BUSINESS RISK
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number10236643
Policy instance 1
Insurance contract or identification number10236643
Number of Individuals Covered317
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $2,692
Total amount of fees paid to insurance companyUSD $714
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $19,424
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,828
Insurance broker organization code?3
Amount paid for insurance broker fees311
Additional information about fees paid to insurance brokerBROKER BONUS
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number0109007
Policy instance 3
Insurance contract or identification number0109007
Number of Individuals Covered766
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $162,957
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $3,411,690
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $162,957
Insurance broker organization code?3
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number000010236643
Policy instance 1
Insurance contract or identification number000010236643
Number of Individuals Covered231
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $2,307
Total amount of fees paid to insurance companyUSD $285
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $15,574
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,307
Amount paid for insurance broker fees285
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number000010236642
Policy instance 2
Insurance contract or identification number000010236642
Number of Individuals Covered351
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $1,457
Total amount of fees paid to insurance companyUSD $102
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&D, SUPPLEMENTAL LIFE, DEPENDENT LIFE
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $13,030
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,457
Amount paid for insurance broker fees102
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
SURENCY LIFE AND HEALTH (National Association of Insurance Commissioners NAIC id number: 13175 )
Policy contract number50790
Policy instance 3
Insurance contract or identification number50790
Number of Individuals Covered204
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $2,670
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $27,105
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,670
Insurance broker organization code?3
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number000010236642
Policy instance 2
Insurance contract or identification number000010236642
Number of Individuals Covered284
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $674
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&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 CarrierUSD $5,114
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $305
Insurance broker organization code?3
DELTA DENTAL OF KANSAS (National Association of Insurance Commissioners NAIC id number: 54615 )
Policy contract number50790
Policy instance 4
Insurance contract or identification number50790
Number of Individuals Covered348
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $3,124
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $187,869
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,124
Insurance broker organization code?3
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number000400001000
Policy instance 5
Insurance contract or identification number000400001000
Number of Individuals Covered109
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $5,561
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedSUPPLEMENTAL LIFE, DEPENDENT LIFE
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $37,071
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,413
Insurance broker organization code?3
BLUE CROSS AND BLUE SHIELD OF KANSAS CITY (National Association of Insurance Commissioners NAIC id number: 47171 )
Policy contract number23813000
Policy instance 6
Insurance contract or identification number23813000
Number of Individuals Covered335
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $60,480
Total amount of fees paid to insurance companyUSD $22,950
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $45,360
Amount paid for insurance broker fees22950
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number000010236643
Policy instance 1
Insurance contract or identification number000010236643
Number of Individuals Covered212
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $2,136
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $14,236
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $844
Insurance broker organization code?3
DELTA DENTAL OF KANSAS (National Association of Insurance Commissioners NAIC id number: 54615 )
Policy contract number50790
Policy instance 4
Insurance contract or identification number50790
Number of Individuals Covered320
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $4,152
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $179,728
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,152
Insurance broker organization code?3
Insurance broker nameSRA INSURANCE AGENCY LLC
BLUE CROSS AND BLUE SHIELD OF KANSAS CITY (National Association of Insurance Commissioners NAIC id number: 47171 )
Policy contract number23813000
Policy instance 2
Insurance contract or identification number23813000
Number of Individuals Covered320
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $69,480
Total amount of fees paid to insurance companyUSD $31,328
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $69,480
Amount paid for insurance broker fees31328
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
Insurance broker nameSRA BENEFITS
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number02053
Policy instance 1
Insurance contract or identification number02053
Number of Individuals Covered247
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $7,647
Total amount of fees paid to insurance companyUSD $88
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&D, SUPPLEMENTAL LIFE, DEPENDENT LIFE
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $49,356
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $7,647
Insurance broker organization code?3
Amount paid for insurance broker fees88
Additional information about fees paid to insurance brokerFEES
Insurance broker nameAXA ASSISTANCE, USA
SURENCY LIFE AND HEALTH (National Association of Insurance Commissioners NAIC id number: 13175 )
Policy contract number50790
Policy instance 3
Insurance contract or identification number50790
Number of Individuals Covered187
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $2,448
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $24,945
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,448
Insurance broker organization code?3
Insurance broker nameSRA INSURANCE AGENCY LLC
BLUE CROSS AND BLUE SHIELD OF KANSAS CITY (National Association of Insurance Commissioners NAIC id number: 47171 )
Policy contract number23813000
Policy instance 2
Insurance contract or identification number23813000
Number of Individuals Covered303
Insurance policy start date2015-01-01
Insurance policy end date2015-12-31
Total amount of commissions paid to insurance brokerUSD $77,364
Total amount of fees paid to insurance companyUSD $25,028
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $77,364
Amount paid for insurance broker fees25028
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
Insurance broker nameSRA BENEFITS
SURENCY LIFE AND HEALTH (National Association of Insurance Commissioners NAIC id number: 13175 )
Policy contract number50790
Policy instance 3
Insurance contract or identification number50790
Number of Individuals Covered145
Insurance policy start date2015-01-01
Insurance policy end date2015-12-31
Total amount of commissions paid to insurance brokerUSD $1,870
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $19,119
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,870
Insurance broker organization code?3
Insurance broker nameSRA INSURANCE AGENCY LLC
DELTA DENTAL OF KANSAS (National Association of Insurance Commissioners NAIC id number: 54615 )
Policy contract number50790
Policy instance 4
Insurance contract or identification number50790
Number of Individuals Covered160
Insurance policy start date2015-01-01
Insurance policy end date2015-12-31
Total amount of commissions paid to insurance brokerUSD $2,934
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $100,586
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,934
Insurance broker organization code?3
Insurance broker nameSRA INSURANCE AGENCY LLC
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number02053
Policy instance 1
Insurance contract or identification number02053
Number of Individuals Covered211
Insurance policy start date2015-01-01
Insurance policy end date2015-12-31
Total amount of commissions paid to insurance brokerUSD $4,578
Total amount of fees paid to insurance companyUSD $73
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&D, SUPPLEMENTAL LIFE & DEPENDENT LIFE
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $78,738
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,578
Insurance broker organization code?3
Amount paid for insurance broker fees73
Additional information about fees paid to insurance brokerFEES
Insurance broker nameAXA ASSISTANCE, USA
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number02053
Policy instance 1
Insurance contract or identification number02053
Number of Individuals Covered195
Insurance policy start date2014-01-01
Insurance policy end date2014-12-31
Total amount of commissions paid to insurance brokerUSD $4,383
Total amount of fees paid to insurance companyUSD $69
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&D, SUPPLEMENTAL LIFE & DEPENDENT LIFE, SUPPLEMENTAL AD&D & DEPENDENT 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 CarrierUSD $72,238
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,383
Insurance broker organization code?3
Amount paid for insurance broker fees69
Additional information about fees paid to insurance brokerTHIRD PARTY ADMINISTRATION FEES
Insurance broker nameAXA ASSISTANCE, USA
BLUE CROSS AND BLUE SHIELD OF KANSAS CITY (National Association of Insurance Commissioners NAIC id number: 47171 )
Policy contract number23813000
Policy instance 2
Insurance contract or identification number23813000
Number of Individuals Covered228
Insurance policy start date2014-01-01
Insurance policy end date2014-12-31
Total amount of commissions paid to insurance brokerUSD $75,360
Total amount of fees paid to insurance companyUSD $22,050
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $75,360
Amount paid for insurance broker fees22050
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
Insurance broker nameSRA BENEFITS
SURENCY LIFE AND HEALTH (National Association of Insurance Commissioners NAIC id number: 13175 )
Policy contract number50790
Policy instance 3
Insurance contract or identification number50790
Number of Individuals Covered131
Insurance policy start date2014-01-01
Insurance policy end date2014-12-31
Total amount of commissions paid to insurance brokerUSD $1,701
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $17,090
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,701
Insurance broker organization code?3
Insurance broker nameSRA INSURANCE AGENCY LLC
DELTA DENTAL OF KANSAS (National Association of Insurance Commissioners NAIC id number: 54615 )
Policy contract number50790
Policy instance 4
Insurance contract or identification number50790
Number of Individuals Covered148
Insurance policy start date2014-01-01
Insurance policy end date2014-12-31
Total amount of commissions paid to insurance brokerUSD $3,107
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $94,038
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,107
Insurance broker organization code?3
Insurance broker nameSRA INSURANCE AGENCY LLC
SURENCY LIFE AND HEALTH (National Association of Insurance Commissioners NAIC id number: 13175 )
Policy contract number50790-000-00002
Policy instance 7
Insurance contract or identification number50790-000-00002
Number of Individuals Covered1
Insurance policy start date2013-01-01
Insurance policy end date2013-12-31
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $47
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
SURENCY LIFE AND HEALTH (National Association of Insurance Commissioners NAIC id number: 13175 )
Policy contract number50790-000-00001
Policy instance 6
Insurance contract or identification number50790-000-00001
Number of Individuals Covered133
Insurance policy start date2013-01-01
Insurance policy end date2013-12-31
Total amount of commissions paid to insurance brokerUSD $1,549
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $15,488
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,549
Insurance broker organization code?3
Insurance broker nameSRA BENEFITS COMPANY, LLC
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number02053
Policy instance 5
Insurance contract or identification number02053
Number of Individuals Covered191
Insurance policy start date2013-01-01
Insurance policy end date2013-12-31
Total amount of commissions paid to insurance brokerUSD $4,183
Life Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $14,346
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,183
Insurance broker organization code?3
Insurance broker nameSRA BENEFITS COMPANY, LLC
DELTA DENTAL OF KANSAS (National Association of Insurance Commissioners NAIC id number: 54615 )
Policy contract number50790-02
Policy instance 4
Insurance contract or identification number50790-02
Number of Individuals Covered2
Insurance policy start date2013-01-01
Insurance policy end date2013-12-31
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $956
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number02053
Policy instance 3
Insurance contract or identification number02053
Number of Individuals Covered72
Insurance policy start date2013-01-01
Insurance policy end date2013-12-31
Total amount of commissions paid to insurance brokerUSD $640
Total amount of fees paid to insurance companyUSD $69
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $18,958
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $640
Insurance broker organization code?3
Amount paid for insurance broker fees69
Additional information about fees paid to insurance brokerTHIRD PARTY ADMINISTRATION FEES
Insurance broker nameAXA ASSISTANCE, USA
DELTA DENTAL OF KANSAS (National Association of Insurance Commissioners NAIC id number: 54615 )
Policy contract number50790-01
Policy instance 2
Insurance contract or identification number50790-01
Number of Individuals Covered149
Insurance policy start date2013-01-01
Insurance policy end date2013-12-31
Total amount of commissions paid to insurance brokerUSD $1,944
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $94,317
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,944
Insurance broker organization code?3
Insurance broker nameSR&A BENEFITS COMPANY, LLC
BLUE CROSS AND BLUE SHIELD OF KANSAS CITY (National Association of Insurance Commissioners NAIC id number: 47171 )
Policy contract number23813000
Policy instance 1
Insurance contract or identification number23813000
Number of Individuals Covered390
Insurance policy start date2013-01-01
Insurance policy end date2013-12-31
Total amount of commissions paid to insurance brokerUSD $75,360
Total amount of fees paid to insurance companyUSD $22,035
Health Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $75,360
Amount paid for insurance broker fees22035
Additional information about fees paid to insurance brokerADMINISTRATIVE FEES NON-MONETARY COMPENSATION
Insurance broker organization code?3
Insurance broker nameSR&A BENEFITS COMPANY, LLC
BLUE CROSS AND BLUE SHIELD OF KANSAS CITY (National Association of Insurance Commissioners NAIC id number: 47171 )
Policy contract number23813000
Policy instance 1
Insurance contract or identification number23813000
Number of Individuals Covered388
Insurance policy start date2012-01-01
Insurance policy end date2012-12-31
Total amount of commissions paid to insurance brokerUSD $69,422
Total amount of fees paid to insurance companyUSD $21,765
Health Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $69,422
Amount paid for insurance broker fees21765
Additional information about fees paid to insurance brokerADMINISTRATIVE FEES NON-MONETARY COMPENSATION
Insurance broker organization code?3
Insurance broker nameSR&A BENEFITS COMPANY, LLC
DELTA DENTAL OF KANSAS (National Association of Insurance Commissioners NAIC id number: 54615 )
Policy contract number50790-02
Policy instance 4
Insurance contract or identification number50790-02
Number of Individuals Covered3
Insurance policy start date2012-01-01
Insurance policy end date2012-12-31
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $2,189
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number02053
Policy instance 3
Insurance contract or identification number02053
Number of Individuals Covered57
Insurance policy start date2012-01-01
Insurance policy end date2012-12-31
Total amount of commissions paid to insurance brokerUSD $1,572
Total amount of fees paid to insurance companyUSD $71
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $19,486
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,572
Insurance broker organization code?3
Amount paid for insurance broker fees71
Additional information about fees paid to insurance brokerTHIRD PARTY ADMINISTRATION FEES
Insurance broker nameAXA ASSISTANCE, USA
DELTA DENTAL OF KANSAS (National Association of Insurance Commissioners NAIC id number: 54615 )
Policy contract number50790-01
Policy instance 2
Insurance contract or identification number50790-01
Number of Individuals Covered152
Insurance policy start date2012-01-01
Insurance policy end date2012-12-31
Total amount of commissions paid to insurance brokerUSD $2,497
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $100,734
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,497
Insurance broker organization code?3
Insurance broker nameSR&A BENEFITS COMPANY, LLC
SURENCY LIFE AND HEALTH (National Association of Insurance Commissioners NAIC id number: 13175 )
Policy contract number50790-000-00001
Policy instance 6
Insurance contract or identification number50790-000-00001
Number of Individuals Covered135
Insurance policy start date2012-01-01
Insurance policy end date2012-12-31
Total amount of commissions paid to insurance brokerUSD $1,477
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $14,773
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,477
Insurance broker organization code?3
Insurance broker nameSRA BENEFITS COMPANY, LLC
SURENCY LIFE AND HEALTH (National Association of Insurance Commissioners NAIC id number: 13175 )
Policy contract number50790-000-00002
Policy instance 7
Insurance contract or identification number50790-000-00002
Number of Individuals Covered1
Insurance policy start date2012-01-01
Insurance policy end date2012-12-31
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $171
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number02053
Policy instance 5
Insurance contract or identification number02053
Number of Individuals Covered200
Insurance policy start date2012-01-01
Insurance policy end date2012-12-31
Total amount of commissions paid to insurance brokerUSD $4,211
Life Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $14,186
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,211
Insurance broker organization code?3
Insurance broker nameSRA BENEFITS COMPANY, LLC
SURENCY LIFE AND HEALTH (National Association of Insurance Commissioners NAIC id number: 13175 )
Policy contract number50790-000-00001
Policy instance 6
Insurance contract or identification number50790-000-00001
Number of Individuals Covered134
Insurance policy start date2011-01-01
Insurance policy end date2011-12-31
Total amount of commissions paid to insurance brokerUSD $1,152
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $11,516
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number02053
Policy instance 5
Insurance contract or identification number02053
Number of Individuals Covered200
Insurance policy start date2011-01-01
Insurance policy end date2011-12-31
Total amount of commissions paid to insurance brokerUSD $4,003
Life Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH DISMEMBERMENT
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
DELTA DENTAL OF KANSAS (National Association of Insurance Commissioners NAIC id number: 54615 )
Policy contract number50790-02
Policy instance 4
Insurance contract or identification number50790-02
Number of Individuals Covered5
Insurance policy start date2011-01-01
Insurance policy end date2011-12-31
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $2,721
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number02053
Policy instance 3
Insurance contract or identification number02053
Number of Individuals Covered76
Insurance policy start date2011-01-01
Insurance policy end date2011-12-31
Total amount of commissions paid to insurance brokerUSD $139
Total amount of fees paid to insurance companyUSD $68
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $17,988
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
BLUE CROSS AND BLUE SHIELD OF KANSAS CITY (National Association of Insurance Commissioners NAIC id number: 47171 )
Policy contract number23813000
Policy instance 1
Insurance contract or identification number23813000
Number of Individuals Covered373
Insurance policy start date2011-01-01
Insurance policy end date2011-12-31
Total amount of commissions paid to insurance brokerUSD $59,033
Total amount of fees paid to insurance companyUSD $19,665
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,500,838
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
DELTA DENTAL OF KANSAS (National Association of Insurance Commissioners NAIC id number: 54615 )
Policy contract number50790-01
Policy instance 2
Insurance contract or identification number50790-01
Number of Individuals Covered154
Insurance policy start date2011-01-01
Insurance policy end date2011-12-31
Total amount of commissions paid to insurance brokerUSD $2,228
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $93,138
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
DELTA DENTAL OF KANSAS (National Association of Insurance Commissioners NAIC id number: 54615 )
Policy contract number50790-02
Policy instance 5
Insurance contract or identification number50790-02
Number of Individuals Covered8
Insurance policy start date2010-01-01
Insurance policy end date2010-12-31
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $4,231
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number02053
Policy instance 3
Insurance contract or identification number02053
Number of Individuals Covered73
Insurance policy start date2010-01-01
Insurance policy end date2010-12-31
Total amount of commissions paid to insurance brokerUSD $699
Total amount of fees paid to insurance companyUSD $69
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $15,594
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number02053
Policy instance 6
Insurance contract or identification number02053
Number of Individuals Covered185
Insurance policy start date2010-01-01
Insurance policy end date2010-12-31
Total amount of commissions paid to insurance brokerUSD $4,620
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $26,439
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
SURENCY LIFE AND HEALTH (National Association of Insurance Commissioners NAIC id number: 13175 )
Policy contract number50790-000-00001
Policy instance 7
Insurance contract or identification number50790-000-00001
Number of Individuals Covered119
Insurance policy start date2010-01-01
Insurance policy end date2010-12-31
Total amount of commissions paid to insurance brokerUSD $1,172
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $11,717
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
DELTA DENTAL OF KANSAS (National Association of Insurance Commissioners NAIC id number: 54615 )
Policy contract number50790-01
Policy instance 2
Insurance contract or identification number50790-01
Number of Individuals Covered150
Insurance policy start date2010-01-01
Insurance policy end date2010-12-31
Total amount of commissions paid to insurance brokerUSD $1,918
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $92,249
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
BLUE CROSS AND BLUE SHIELD OF KANSAS CITY (National Association of Insurance Commissioners NAIC id number: 47171 )
Policy contract number23813000
Policy instance 1
Insurance contract or identification number23813000
Number of Individuals Covered347
Insurance policy start date2009-12-01
Insurance policy end date2010-11-30
Total amount of commissions paid to insurance brokerUSD $57,525
Total amount of fees paid to insurance companyUSD $17,252
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,443,491
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
SURENCY LIFE AND HEALTH (National Association of Insurance Commissioners NAIC id number: 13175 )
Policy contract number50790-02
Policy instance 4
Insurance contract or identification number50790-02
Number of Individuals Covered5
Insurance policy start date2010-01-01
Insurance policy end date2010-12-31
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $406
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number02053
Policy instance 6
Insurance contract or identification number02053
Number of Individuals Covered193
Insurance policy start date2009-01-01
Insurance policy end date2009-12-31
Total amount of commissions paid to insurance brokerUSD $3,565
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH & DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $20,419
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $3,565
Insurance broker organization code?3
Insurance broker nameSRA BENEFITS COMPANY, LLC
DELTA DENTAL OF KANSAS (National Association of Insurance Commissioners NAIC id number: 54615 )
Policy contract number50790-000-00001
Policy instance 2
Insurance contract or identification number50790-000-00001
Number of Individuals Covered155
Insurance policy start date2009-01-01
Insurance policy end date2009-12-31
Total amount of commissions paid to insurance brokerUSD $1,867
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $98,059
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $1,867
Insurance broker organization code?3
Insurance broker nameSRA BENEFITS COMPANY, LLC
DELTA DENTAL OF KANSAS (National Association of Insurance Commissioners NAIC id number: 54615 )
Policy contract number50790-000-00002
Policy instance 3
Insurance contract or identification number50790-000-00002
Number of Individuals Covered1
Insurance policy start date2009-01-01
Insurance policy end date2009-12-31
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $2,929
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
SURENCY LIFE AND HEALTH (National Association of Insurance Commissioners NAIC id number: 13175 )
Policy contract number50790-000-00001
Policy instance 4
Insurance contract or identification number50790-000-00001
Number of Individuals Covered131
Insurance policy start date2009-01-01
Insurance policy end date2009-12-31
Total amount of commissions paid to insurance brokerUSD $652
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $6,518
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $652
Insurance broker organization code?3
Insurance broker nameSRA BENEFITS COMPANY, LLC
PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )
Policy contract number02053
Policy instance 5
Insurance contract or identification number02053
Number of Individuals Covered73
Insurance policy start date2009-01-01
Insurance policy end date2009-12-31
Total amount of fees paid to insurance companyUSD $29
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $7,921
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Amount paid for insurance broker fees29
Additional information about fees paid to insurance brokerTHIRD PARTY ADMINISTRATION FEES
Insurance broker organization code?5
Insurance broker nameAXA ASSISTANCE, USA
BLUE CROSS AND BLUE SHIELD OF KANSAS CITY (National Association of Insurance Commissioners NAIC id number: 47171 )
Policy contract number23813000
Policy instance 1
Insurance contract or identification number23813000
Number of Individuals Covered350
Insurance policy start date2008-12-01
Insurance policy end date2009-11-30
Total amount of commissions paid to insurance brokerUSD $66,473
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $167,833
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $66,473
Insurance broker organization code?3
Insurance broker nameSRA BENEFITS COMPANY, LLC

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