RALLY HOUSE has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan SAMPLER STORES INC. DBA RALLY HOUSE AND KANSAS SAMPLER WELLNESS PLAN
401k plan membership statisitcs for SAMPLER STORES INC. DBA RALLY HOUSE AND KANSAS SAMPLER WELLNESS PLAN
| Measure | Date | Value |
|---|
| 2023: SAMPLER STORES INC. DBA RALLY HOUSE AND KANSAS SAMPLER WELLNESS PLAN 2023 401k membership |
|---|
| Total participants, beginning-of-year | 2023-01-01 | 432 |
| Total number of active participants reported on line 7a of the Form 5500 | 2023-01-01 | 588 |
| Number of retired or separated participants receiving benefits | 2023-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2023-01-01 | 0 |
| Total of all active and inactive participants | 2023-01-01 | 588 |
| Total participants | 2023-01-01 | 588 |
| 2022: SAMPLER STORES INC. DBA RALLY HOUSE AND KANSAS SAMPLER WELLNESS PLAN 2022 401k membership |
|---|
| Total participants, beginning-of-year | 2022-01-01 | 271 |
| Total number of active participants reported on line 7a of the Form 5500 | 2022-01-01 | 432 |
| Number of retired or separated participants receiving benefits | 2022-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2022-01-01 | 0 |
| Total of all active and inactive participants | 2022-01-01 | 432 |
| Total participants | 2022-01-01 | 432 |
| Number of employers contributing to the scheme | 2022-01-01 | 0 |
| 2021: SAMPLER STORES INC. DBA RALLY HOUSE AND KANSAS SAMPLER WELLNESS PLAN 2021 401k membership |
|---|
| Total participants, beginning-of-year | 2021-03-01 | 195 |
| Total number of active participants reported on line 7a of the Form 5500 | 2021-03-01 | 271 |
| Number of retired or separated participants receiving benefits | 2021-03-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2021-03-01 | 0 |
| Total of all active and inactive participants | 2021-03-01 | 271 |
| Number of employers contributing to the scheme | 2021-03-01 | 0 |
| 2020: SAMPLER STORES INC. DBA RALLY HOUSE AND KANSAS SAMPLER WELLNESS PLAN 2020 401k membership |
|---|
| Total participants, beginning-of-year | 2020-03-01 | 195 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-03-01 | 195 |
| Number of retired or separated participants receiving benefits | 2020-03-01 | 3 |
| Number of other retired or separated participants entitled to future benefits | 2020-03-01 | 0 |
| Total of all active and inactive participants | 2020-03-01 | 198 |
| Number of employers contributing to the scheme | 2020-03-01 | 0 |
| 2019: SAMPLER STORES INC. DBA RALLY HOUSE AND KANSAS SAMPLER WELLNESS PLAN 2019 401k membership |
|---|
| Total participants, beginning-of-year | 2019-03-01 | 127 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-03-01 | 131 |
| Number of retired or separated participants receiving benefits | 2019-03-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2019-03-01 | 0 |
| Total of all active and inactive participants | 2019-03-01 | 131 |
| 2018: SAMPLER STORES INC. DBA RALLY HOUSE AND KANSAS SAMPLER WELLNESS PLAN 2018 401k membership |
|---|
| Total participants, beginning-of-year | 2018-03-01 | 129 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-03-01 | 127 |
| Number of retired or separated participants receiving benefits | 2018-03-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2018-03-01 | 0 |
| Total of all active and inactive participants | 2018-03-01 | 127 |
| 2017: SAMPLER STORES INC. DBA RALLY HOUSE AND KANSAS SAMPLER WELLNESS PLAN 2017 401k membership |
|---|
| Total participants, beginning-of-year | 2017-03-01 | 145 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-03-01 | 129 |
| Number of retired or separated participants receiving benefits | 2017-03-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2017-03-01 | 0 |
| Total of all active and inactive participants | 2017-03-01 | 129 |
| 2016: SAMPLER STORES INC. DBA RALLY HOUSE AND KANSAS SAMPLER WELLNESS PLAN 2016 401k membership |
|---|
| Total participants, beginning-of-year | 2016-03-01 | 106 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-03-01 | 143 |
| Number of retired or separated participants receiving benefits | 2016-03-01 | 2 |
| Number of other retired or separated participants entitled to future benefits | 2016-03-01 | 0 |
| Total of all active and inactive participants | 2016-03-01 | 145 |
| 2014: SAMPLER STORES INC. DBA RALLY HOUSE AND KANSAS SAMPLER WELLNESS PLAN 2014 401k membership |
|---|
| Total participants, beginning-of-year | 2014-12-01 | 176 |
| Total number of active participants reported on line 7a of the Form 5500 | 2014-12-01 | 176 |
| Number of retired or separated participants receiving benefits | 2014-12-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2014-12-01 | 0 |
| Total of all active and inactive participants | 2014-12-01 | 176 |
| 2023: SAMPLER STORES INC. DBA RALLY HOUSE AND KANSAS SAMPLER WELLNESS PLAN 2023 form 5500 responses |
|---|
| 2023-01-01 | Type of plan entity | Single employer plan |
| 2023-01-01 | Submission has been amended | No |
| 2023-01-01 | This submission is the final filing | No |
| 2023-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2023-01-01 | Plan is a collectively bargained plan | No |
| 2023-01-01 | Plan funding arrangement – Insurance | Yes |
| 2023-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2023-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2023-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2022: SAMPLER STORES INC. DBA RALLY HOUSE AND KANSAS SAMPLER WELLNESS PLAN 2022 form 5500 responses |
|---|
| 2022-01-01 | Type of plan entity | Single employer plan |
| 2022-01-01 | Submission has been amended | No |
| 2022-01-01 | This submission is the final filing | No |
| 2022-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2022-01-01 | Plan is a collectively bargained plan | No |
| 2022-01-01 | Plan funding arrangement – Insurance | Yes |
| 2022-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2022-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2022-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2021: SAMPLER STORES INC. DBA RALLY HOUSE AND KANSAS SAMPLER WELLNESS PLAN 2021 form 5500 responses |
|---|
| 2021-03-01 | Type of plan entity | Single employer plan |
| 2021-03-01 | This return/report is a short plan year return/report (less than 12 months) | Yes |
| 2021-03-01 | Plan funding arrangement – Insurance | Yes |
| 2021-03-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2021-03-01 | Plan benefit arrangement – Insurance | Yes |
| 2021-03-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2020: SAMPLER STORES INC. DBA RALLY HOUSE AND KANSAS SAMPLER WELLNESS PLAN 2020 form 5500 responses |
|---|
| 2020-03-01 | Type of plan entity | Single employer plan |
| 2020-03-01 | Plan funding arrangement – Insurance | Yes |
| 2020-03-01 | Plan benefit arrangement – Insurance | Yes |
| 2019: SAMPLER STORES INC. DBA RALLY HOUSE AND KANSAS SAMPLER WELLNESS PLAN 2019 form 5500 responses |
|---|
| 2019-03-01 | Type of plan entity | Single employer plan |
| 2019-03-01 | Plan funding arrangement – Insurance | Yes |
| 2019-03-01 | Plan benefit arrangement – Insurance | Yes |
| 2018: SAMPLER STORES INC. DBA RALLY HOUSE AND KANSAS SAMPLER WELLNESS PLAN 2018 form 5500 responses |
|---|
| 2018-03-01 | Type of plan entity | Single employer plan |
| 2018-03-01 | Plan funding arrangement – Insurance | Yes |
| 2018-03-01 | Plan benefit arrangement – Insurance | Yes |
| 2017: SAMPLER STORES INC. DBA RALLY HOUSE AND KANSAS SAMPLER WELLNESS PLAN 2017 form 5500 responses |
|---|
| 2017-03-01 | Type of plan entity | Single employer plan |
| 2017-03-01 | Plan funding arrangement – Insurance | Yes |
| 2017-03-01 | Plan benefit arrangement – Insurance | Yes |
| 2016: SAMPLER STORES INC. DBA RALLY HOUSE AND KANSAS SAMPLER WELLNESS PLAN 2016 form 5500 responses |
|---|
| 2016-03-01 | Type of plan entity | Single employer plan |
| 2016-03-01 | First time form 5500 has been submitted | Yes |
| 2016-03-01 | Plan funding arrangement – Insurance | Yes |
| 2016-03-01 | Plan benefit arrangement – Insurance | Yes |
| 2014: SAMPLER STORES INC. DBA RALLY HOUSE AND KANSAS SAMPLER WELLNESS PLAN 2014 form 5500 responses |
|---|
| 2014-12-01 | Type of plan entity | Single employer plan |
| 2014-12-01 | First time form 5500 has been submitted | Yes |
| 2014-12-01 | Submission has been amended | No |
| 2014-12-01 | This submission is the final filing | No |
| 2014-12-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2014-12-01 | Plan is a collectively bargained plan | No |
| 2014-12-01 | Plan funding arrangement – Insurance | Yes |
| 2014-12-01 | Plan benefit arrangement – Insurance | Yes |
| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
| Policy contract number | 5975856, 233548 |
| Policy instance | 2 |
| Insurance contract or identification number | 5975856, 233548 | | Number of Individuals Covered | 588 | | Insurance policy start date | 2023-01-01 | | Insurance policy end date | 2023-12-31 | | Total amount of commissions paid to insurance broker | USD $28,563 | | Total amount of fees paid to insurance company | USD $3,947 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | AD&D, ACCIDENTAL INSURANCE | | 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 $191,004 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
| Policy contract number | 00637456 |
| Policy instance | 1 |
| Insurance contract or identification number | 00637456 | | Number of Individuals Covered | 323 | | Insurance policy start date | 2023-01-01 | | Insurance policy end date | 2023-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $41,100 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $441,156 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| WESTPORT INSURANCE CORP (National Association of Insurance Commissioners NAIC id number: 34207 ) |
| Policy contract number | 417002414888 |
| Policy instance | 2 |
| Insurance contract or identification number | 417002414888 | | Number of Individuals Covered | 234 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | TRANPLANT | | 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 $375,009 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $0 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
| Policy contract number | 5975856 |
| Policy instance | 1 |
| Insurance contract or identification number | 5975856 | | Number of Individuals Covered | 432 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $35,445 | | Total amount of fees paid to insurance company | USD $16,269 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | AD&D | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $141,233 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,524 | | Amount paid for insurance broker fees | 15 | | Additional information about fees paid to insurance broker | NON-MONETARY COMPENSATION | | Insurance broker organization code? | 3 |
|
| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
| Policy contract number | 5975856 |
| Policy instance | 1 |
| Insurance contract or identification number | 5975856 | | Number of Individuals Covered | 338 | | Insurance policy start date | 2021-03-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $18,906 | | Total amount of fees paid to insurance company | USD $7,411 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT,CRITICAL ILLNESS,ACCIDENT | | Welfare Benefit Premiums Paid to Carrier | USD $176,507 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $12,506 | | Amount paid for insurance broker fees | 129 | | Additional information about fees paid to insurance broker | NON-MONETARY COMPENSATION | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL OF KANSAS (National Association of Insurance Commissioners NAIC id number: 54615 ) |
| Policy contract number | 40213-00002 |
| Policy instance | 1 |
| Insurance contract or identification number | 40213-00002 | | Number of Individuals Covered | 1 | | Insurance policy start date | 2020-03-01 | | Insurance policy end date | 2021-02-28 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $710 | | 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 number | 37067000 |
| Policy instance | 2 |
| Insurance contract or identification number | 37067000 | | Number of Individuals Covered | 173 | | Insurance policy start date | 2020-03-01 | | Insurance policy end date | 2021-02-28 | | Total amount of commissions paid to insurance broker | USD $40,975 | | Total amount of fees paid to insurance company | USD $7,749 | | Health Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $25,825 | | Amount paid for insurance broker fees | 7749 | | Additional information about fees paid to insurance broker | ADMINISTRATIVE SERVICES | | Insurance broker organization code? | 3 |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 247810 |
| Policy instance | 3 |
| Insurance contract or identification number | 247810 | | Number of Individuals Covered | 192 | | Insurance policy start date | 2020-03-01 | | Insurance policy end date | 2021-02-28 | | Total amount of commissions paid to insurance broker | USD $10,851 | | Total amount of fees paid to insurance company | USD $2,822 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT, ACCIDENT, CRITICAL ILLNESS | | Welfare Benefit Premiums Paid to Carrier | USD $85,938 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,766 | | Amount paid for insurance broker fees | 2822 | | Additional information about fees paid to insurance broker | BONUS | | Insurance broker organization code? | 3 |
|
| BLUE CROSS AND BLUE SHIELD OF KANSAS CITY (National Association of Insurance Commissioners NAIC id number: 47171 ) |
| Policy contract number | 37067000 |
| Policy instance | 4 |
| Insurance contract or identification number | 37067000 | | Number of Individuals Covered | 185 | | Insurance policy start date | 2019-03-01 | | Insurance policy end date | 2020-02-29 | | Total amount of commissions paid to insurance broker | USD $24,769 | | Total amount of fees paid to insurance company | USD $13,212 | | Health Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $24,769 | | Amount paid for insurance broker fees | 13212 | | Additional information about fees paid to insurance broker | ADMINISTRATIVE SERVICES | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL OF KANSAS (National Association of Insurance Commissioners NAIC id number: 54615 ) |
| Policy contract number | 40213-00001 |
| Policy instance | 3 |
| Insurance contract or identification number | 40213-00001 | | Number of Individuals Covered | 137 | | Insurance policy start date | 2019-03-01 | | Insurance policy end date | 2020-02-29 | | Total amount of commissions paid to insurance broker | USD $3,624 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $48,539 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,624 | | Insurance broker organization code? | 3 |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 247810 |
| Policy instance | 2 |
| Insurance contract or identification number | 247810 | | Number of Individuals Covered | 211 | | Insurance policy start date | 2019-03-01 | | Insurance policy end date | 2020-02-29 | | Total amount of commissions paid to insurance broker | USD $9,856 | | Total amount of fees paid to insurance company | USD $1,115 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | CI, AD&D, ACCIDENT | | Welfare Benefit Premiums Paid to Carrier | USD $58,330 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $9,856 | | Amount paid for insurance broker fees | 1115 | | 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 | 906124 |
| Policy instance | 1 |
| Insurance contract or identification number | 906124 | | Number of Individuals Covered | 118 | | Insurance policy start date | 2019-03-01 | | Insurance policy end date | 2020-02-29 | | Total amount of commissions paid to insurance broker | USD $1,298 | | Total amount of fees paid to insurance company | USD $558 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $13,259 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,298 | | Amount paid for insurance broker fees | 558 | | 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 | 906124 |
| Policy instance | 1 |
| Insurance contract or identification number | 906124 | | Number of Individuals Covered | 108 | | Insurance policy start date | 2018-03-01 | | Insurance policy end date | 2019-02-28 | | Total amount of commissions paid to insurance broker | USD $1,160 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $13,053 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,160 | | Insurance broker organization code? | 3 |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 247810 |
| Policy instance | 2 |
| Insurance contract or identification number | 247810 | | Number of Individuals Covered | 187 | | Insurance policy start date | 2018-03-01 | | Insurance policy end date | 2019-02-28 | | Total amount of commissions paid to insurance broker | USD $6,042 | | Total amount of fees paid to insurance company | USD $2,534 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | CI, AD&D, ACCIDENT | | Welfare Benefit Premiums Paid to Carrier | USD $40,434 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,042 | | Amount paid for insurance broker fees | 2534 | | Additional information about fees paid to insurance broker | BONUS | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL OF KANSAS (National Association of Insurance Commissioners NAIC id number: 54615 ) |
| Policy contract number | 40213-00001 |
| Policy instance | 3 |
| Insurance contract or identification number | 40213-00001 | | Number of Individuals Covered | 129 | | Insurance policy start date | 2018-03-01 | | Insurance policy end date | 2019-02-28 | | Total amount of commissions paid to insurance broker | USD $3,481 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $47,283 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,481 | | Insurance broker organization code? | 3 |
|
| BLUE CROSS AND BLUE SHIELD OF KANSAS CITY (National Association of Insurance Commissioners NAIC id number: 47171 ) |
| Policy contract number | 37067000 |
| Policy instance | 4 |
| Insurance contract or identification number | 37067000 | | Number of Individuals Covered | 192 | | Insurance policy start date | 2018-03-01 | | Insurance policy end date | 2019-02-28 | | Total amount of commissions paid to insurance broker | USD $25,891 | | Total amount of fees paid to insurance company | USD $13,617 | | Health Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $25,891 | | Amount paid for insurance broker fees | 13617 | | Additional information about fees paid to insurance broker | ADMINISTRATIVE SERVICES | | Insurance broker organization code? | 3 |
|
| BLUE CROSS AND BLUE SHIELD OF KANSAS CITY (National Association of Insurance Commissioners NAIC id number: 47171 ) |
| Policy contract number | 37067000 |
| Policy instance | 4 |
| Insurance contract or identification number | 37067000 | | Number of Individuals Covered | 192 | | Insurance policy start date | 2017-03-01 | | Insurance policy end date | 2018-02-28 | | Total amount of commissions paid to insurance broker | USD $26,095 | | Total amount of fees paid to insurance company | USD $12,714 | | Health Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $26,095 | | Amount paid for insurance broker fees | 12714 | | Additional information about fees paid to insurance broker | ADMINISTRATIVE SERVICES NON-MONETARY COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | ROBERT E MILLER INSURANCE AGCY, INC |
|
| DELTA DENTAL OF KANSAS (National Association of Insurance Commissioners NAIC id number: 54615 ) |
| Policy contract number | 40213-00001, 02 |
| Policy instance | 3 |
| Insurance contract or identification number | 40213-00001, 02 | | Number of Individuals Covered | 135 | | Insurance policy start date | 2017-03-01 | | Insurance policy end date | 2018-02-28 | | Total amount of commissions paid to insurance broker | USD $2,824 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $47,358 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,824 | | Insurance broker organization code? | 3 | | Insurance broker name | ROBERT E MILLER INSURANCE AGCY, INC |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 247810 |
| Policy instance | 2 |
| Insurance contract or identification number | 247810 | | Number of Individuals Covered | 170 | | Insurance policy start date | 2017-03-01 | | Insurance policy end date | 2018-02-28 | | Total amount of commissions paid to insurance broker | USD $7,962 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | CI, AD&D, ACCIDENT | | Welfare Benefit Premiums Paid to Carrier | USD $53,081 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,962 | | Insurance broker organization code? | 3 | | Insurance broker name | ROBERT E MILLER INSURANCE AGCY, INC |
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| SURENCY LIFE AND HEALTH (National Association of Insurance Commissioners NAIC id number: 13175 ) |
| Policy contract number | 40213-00001, 02 |
| Policy instance | 1 |
| Insurance contract or identification number | 40213-00001, 02 | | Number of Individuals Covered | 118 | | Insurance policy start date | 2017-03-01 | | Insurance policy end date | 2018-02-28 | | Total amount of commissions paid to insurance broker | USD $1,365 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $13,788 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,365 | | Insurance broker organization code? | 3 | | Insurance broker name | ROBERT E MILLER INSURANCE AGCY INC |
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