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TEXHOMA CHRISTIAN CARE CENTER, INC HEALTH CARE PLAN 401k Plan overview

Plan NameTEXHOMA CHRISTIAN CARE CENTER, INC HEALTH CARE PLAN
Plan identification number 501

TEXHOMA CHRISTIAN CARE CENTER, INC HEALTH CARE 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

TEXHOMA CHRISTIAN CARE CENTER, INC has sponsored the creation of one or more 401k plans.

Company Name:TEXHOMA CHRISTIAN CARE CENTER, INC
Employer identification number (EIN):510193549
NAIC Classification:623000
NAIC Description: Nursing and Residential Care Facilities

Additional information about TEXHOMA CHRISTIAN CARE CENTER, INC

Jurisdiction of Incorporation: Texas Secretary of State
Incorporation Date: 1976-02-27
Company Identification Number: 0037658301
Legal Registered Office Address: 300 LOOP 11

WICHITA FALLS
United States of America (USA)
76306

More information about TEXHOMA CHRISTIAN CARE CENTER, INC

Form 5500 Filing Information

Submission information for form 5500 for 401k plan TEXHOMA CHRISTIAN CARE CENTER, INC HEALTH CARE PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5012022-01-01ERIC SMITH2023-06-30
5012021-01-01ERIC SMITH2022-07-25
5012020-01-01ERIC SMITH2021-07-22
5012019-01-01ERIC SMITH2020-07-28
5012018-01-01
5012017-01-01RANDAL SULLENGER
5012016-05-01RANDAL SULLENGER
5012015-05-01RANDAL SULLENGER
5012014-05-01RANDAL SULLENGER
5012013-05-01RANDAL SULLENGER
5012012-05-01RANDAL SULLENGER
5012011-05-01RANDAL SULLENGER
5012009-05-01RANDAL SULLENGER
5012008-05-01RANDAL SULLENGER

Plan Statistics for TEXHOMA CHRISTIAN CARE CENTER, INC HEALTH CARE PLAN

401k plan membership statisitcs for TEXHOMA CHRISTIAN CARE CENTER, INC HEALTH CARE PLAN

Measure Date Value
2022: TEXHOMA CHRISTIAN CARE CENTER, INC HEALTH CARE PLAN 2022 401k membership
Total participants, beginning-of-year2022-01-01111
Total number of active participants reported on line 7a of the Form 55002022-01-0198
Number of retired or separated participants receiving benefits2022-01-012
Number of other retired or separated participants entitled to future benefits2022-01-017
Total of all active and inactive participants2022-01-01107
2021: TEXHOMA CHRISTIAN CARE CENTER, INC HEALTH CARE PLAN 2021 401k membership
Total participants, beginning-of-year2021-01-01128
Total number of active participants reported on line 7a of the Form 55002021-01-0195
Number of retired or separated participants receiving benefits2021-01-012
Number of other retired or separated participants entitled to future benefits2021-01-015
Total of all active and inactive participants2021-01-01102
2020: TEXHOMA CHRISTIAN CARE CENTER, INC HEALTH CARE PLAN 2020 401k membership
Total participants, beginning-of-year2020-01-01135
Total number of active participants reported on line 7a of the Form 55002020-01-01117
Number of retired or separated participants receiving benefits2020-01-010
Number of other retired or separated participants entitled to future benefits2020-01-015
Total of all active and inactive participants2020-01-01122
2019: TEXHOMA CHRISTIAN CARE CENTER, INC HEALTH CARE PLAN 2019 401k membership
Total participants, beginning-of-year2019-01-01195
Total number of active participants reported on line 7a of the Form 55002019-01-01185
Number of retired or separated participants receiving benefits2019-01-010
Number of other retired or separated participants entitled to future benefits2019-01-016
Total of all active and inactive participants2019-01-01191
2018: TEXHOMA CHRISTIAN CARE CENTER, INC HEALTH CARE PLAN 2018 401k membership
Total participants, beginning-of-year2018-01-01203
Total number of active participants reported on line 7a of the Form 55002018-01-01205
Number of retired or separated participants receiving benefits2018-01-010
Number of other retired or separated participants entitled to future benefits2018-01-017
Total of all active and inactive participants2018-01-01212
2017: TEXHOMA CHRISTIAN CARE CENTER, INC HEALTH CARE PLAN 2017 401k membership
Total participants, beginning-of-year2017-01-01172
Total number of active participants reported on line 7a of the Form 55002017-01-01143
Number of retired or separated participants receiving benefits2017-01-011
Number of other retired or separated participants entitled to future benefits2017-01-016
Total of all active and inactive participants2017-01-01150
2016: TEXHOMA CHRISTIAN CARE CENTER, INC HEALTH CARE PLAN 2016 401k membership
Total participants, beginning-of-year2016-05-01228
Total number of active participants reported on line 7a of the Form 55002016-05-01149
Number of retired or separated participants receiving benefits2016-05-010
Number of other retired or separated participants entitled to future benefits2016-05-018
Total of all active and inactive participants2016-05-01157
2015: TEXHOMA CHRISTIAN CARE CENTER, INC HEALTH CARE PLAN 2015 401k membership
Total participants, beginning-of-year2015-05-01214
Total number of active participants reported on line 7a of the Form 55002015-05-01220
Number of retired or separated participants receiving benefits2015-05-010
Number of other retired or separated participants entitled to future benefits2015-05-014
Total of all active and inactive participants2015-05-01224
2014: TEXHOMA CHRISTIAN CARE CENTER, INC HEALTH CARE PLAN 2014 401k membership
Total participants, beginning-of-year2014-05-01146
Total number of active participants reported on line 7a of the Form 55002014-05-01127
Number of retired or separated participants receiving benefits2014-05-011
Number of other retired or separated participants entitled to future benefits2014-05-010
Total of all active and inactive participants2014-05-01128
2013: TEXHOMA CHRISTIAN CARE CENTER, INC HEALTH CARE PLAN 2013 401k membership
Total participants, beginning-of-year2013-05-01159
Total number of active participants reported on line 7a of the Form 55002013-05-01134
Number of retired or separated participants receiving benefits2013-05-010
Number of other retired or separated participants entitled to future benefits2013-05-010
Total of all active and inactive participants2013-05-01134
2012: TEXHOMA CHRISTIAN CARE CENTER, INC HEALTH CARE PLAN 2012 401k membership
Total participants, beginning-of-year2012-05-01139
Total number of active participants reported on line 7a of the Form 55002012-05-01119
Number of retired or separated participants receiving benefits2012-05-011
Number of other retired or separated participants entitled to future benefits2012-05-010
Total of all active and inactive participants2012-05-01120
2011: TEXHOMA CHRISTIAN CARE CENTER, INC HEALTH CARE PLAN 2011 401k membership
Total participants, beginning-of-year2011-05-01137
Total number of active participants reported on line 7a of the Form 55002011-05-01122
Number of retired or separated participants receiving benefits2011-05-011
Number of other retired or separated participants entitled to future benefits2011-05-016
Total of all active and inactive participants2011-05-01129
2009: TEXHOMA CHRISTIAN CARE CENTER, INC HEALTH CARE PLAN 2009 401k membership
Total participants, beginning-of-year2009-05-01101
Total number of active participants reported on line 7a of the Form 55002009-05-01110
Number of retired or separated participants receiving benefits2009-05-010
Number of other retired or separated participants entitled to future benefits2009-05-013
Total of all active and inactive participants2009-05-01113
2008: TEXHOMA CHRISTIAN CARE CENTER, INC HEALTH CARE PLAN 2008 401k membership
Total participants, beginning-of-year2008-05-01118
Total number of active participants reported on line 7a of the Form 55002008-05-0190
Number of retired or separated participants receiving benefits2008-05-010
Number of other retired or separated participants entitled to future benefits2008-05-012
Total of all active and inactive participants2008-05-0192

Form 5500 Responses for TEXHOMA CHRISTIAN CARE CENTER, INC HEALTH CARE PLAN

2022: TEXHOMA CHRISTIAN CARE CENTER, INC HEALTH CARE PLAN 2022 form 5500 responses
2022-01-01Type of plan entitySingle employer plan
2022-01-01Submission has been amendedNo
2022-01-01This submission is the final filingNo
2022-01-01This return/report is a short plan year return/report (less than 12 months)No
2022-01-01Plan is a collectively bargained planNo
2022-01-01Plan funding arrangement – InsuranceYes
2022-01-01Plan funding arrangement – General assets of the sponsorYes
2022-01-01Plan benefit arrangement – InsuranceYes
2022-01-01Plan benefit arrangement – General assets of the sponsorYes
2021: TEXHOMA CHRISTIAN CARE CENTER, INC HEALTH CARE PLAN 2021 form 5500 responses
2021-01-01Type of plan entitySingle employer plan
2021-01-01Submission has been amendedNo
2021-01-01This submission is the final filingNo
2021-01-01This return/report is a short plan year return/report (less than 12 months)No
2021-01-01Plan is a collectively bargained planNo
2021-01-01Plan funding arrangement – InsuranceYes
2021-01-01Plan funding arrangement – General assets of the sponsorYes
2021-01-01Plan benefit arrangement – InsuranceYes
2021-01-01Plan benefit arrangement – General assets of the sponsorYes
2020: TEXHOMA CHRISTIAN CARE CENTER, INC HEALTH CARE 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: TEXHOMA CHRISTIAN CARE CENTER, INC HEALTH CARE 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 funding arrangement – General assets of the sponsorYes
2019-01-01Plan benefit arrangement – InsuranceYes
2019-01-01Plan benefit arrangement – General assets of the sponsorYes
2018: TEXHOMA CHRISTIAN CARE CENTER, INC HEALTH CARE 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: TEXHOMA CHRISTIAN CARE CENTER, INC HEALTH CARE 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: TEXHOMA CHRISTIAN CARE CENTER, INC HEALTH CARE PLAN 2016 form 5500 responses
2016-05-01Type of plan entitySingle employer plan
2016-05-01Submission has been amendedNo
2016-05-01This submission is the final filingNo
2016-05-01This return/report is a short plan year return/report (less than 12 months)Yes
2016-05-01Plan is a collectively bargained planNo
2016-05-01Plan funding arrangement – InsuranceYes
2016-05-01Plan funding arrangement – General assets of the sponsorYes
2016-05-01Plan benefit arrangement – InsuranceYes
2016-05-01Plan benefit arrangement – General assets of the sponsorYes
2015: TEXHOMA CHRISTIAN CARE CENTER, INC HEALTH CARE PLAN 2015 form 5500 responses
2015-05-01Type of plan entitySingle employer plan
2015-05-01Submission has been amendedNo
2015-05-01This submission is the final filingNo
2015-05-01This return/report is a short plan year return/report (less than 12 months)No
2015-05-01Plan is a collectively bargained planNo
2015-05-01Plan funding arrangement – InsuranceYes
2015-05-01Plan funding arrangement – General assets of the sponsorYes
2015-05-01Plan benefit arrangement – InsuranceYes
2015-05-01Plan benefit arrangement – General assets of the sponsorYes
2014: TEXHOMA CHRISTIAN CARE CENTER, INC HEALTH CARE PLAN 2014 form 5500 responses
2014-05-01Type of plan entitySingle employer plan
2014-05-01Submission has been amendedNo
2014-05-01This submission is the final filingNo
2014-05-01This return/report is a short plan year return/report (less than 12 months)No
2014-05-01Plan is a collectively bargained planNo
2014-05-01Plan funding arrangement – InsuranceYes
2014-05-01Plan funding arrangement – General assets of the sponsorYes
2014-05-01Plan benefit arrangement – InsuranceYes
2014-05-01Plan benefit arrangement – General assets of the sponsorYes
2013: TEXHOMA CHRISTIAN CARE CENTER, INC HEALTH CARE PLAN 2013 form 5500 responses
2013-05-01Type of plan entitySingle employer plan
2013-05-01Submission has been amendedNo
2013-05-01This submission is the final filingNo
2013-05-01This return/report is a short plan year return/report (less than 12 months)No
2013-05-01Plan is a collectively bargained planNo
2013-05-01Plan funding arrangement – InsuranceYes
2013-05-01Plan funding arrangement – General assets of the sponsorYes
2013-05-01Plan benefit arrangement – InsuranceYes
2013-05-01Plan benefit arrangement – General assets of the sponsorYes
2012: TEXHOMA CHRISTIAN CARE CENTER, INC HEALTH CARE PLAN 2012 form 5500 responses
2012-05-01Type of plan entitySingle employer plan
2012-05-01Submission has been amendedNo
2012-05-01This submission is the final filingNo
2012-05-01This return/report is a short plan year return/report (less than 12 months)No
2012-05-01Plan is a collectively bargained planNo
2012-05-01Plan funding arrangement – InsuranceYes
2012-05-01Plan benefit arrangement – InsuranceYes
2011: TEXHOMA CHRISTIAN CARE CENTER, INC HEALTH CARE PLAN 2011 form 5500 responses
2011-05-01Type of plan entitySingle employer plan
2011-05-01Submission has been amendedNo
2011-05-01This submission is the final filingNo
2011-05-01This return/report is a short plan year return/report (less than 12 months)No
2011-05-01Plan is a collectively bargained planNo
2011-05-01Plan funding arrangement – InsuranceYes
2011-05-01Plan benefit arrangement – InsuranceYes
2009: TEXHOMA CHRISTIAN CARE CENTER, INC HEALTH CARE PLAN 2009 form 5500 responses
2009-05-01Type of plan entitySingle employer plan
2009-05-01Submission has been amendedNo
2009-05-01This submission is the final filingNo
2009-05-01This return/report is a short plan year return/report (less than 12 months)No
2009-05-01Plan is a collectively bargained planNo
2009-05-01Plan funding arrangement – InsuranceYes
2009-05-01Plan funding arrangement – General assets of the sponsorYes
2009-05-01Plan benefit arrangement – InsuranceYes
2009-05-01Plan benefit arrangement – General assets of the sponsorYes
2008: TEXHOMA CHRISTIAN CARE CENTER, INC HEALTH CARE PLAN 2008 form 5500 responses
2008-05-01Type of plan entitySingle employer plan
2008-05-01First time form 5500 has been submittedYes
2008-05-01Submission has been amendedNo
2008-05-01This submission is the final filingNo
2008-05-01This return/report is a short plan year return/report (less than 12 months)No
2008-05-01Plan is a collectively bargained planNo
2008-05-01Plan funding arrangement – InsuranceYes
2008-05-01Plan funding arrangement – General assets of the sponsorYes
2008-05-01Plan benefit arrangement – InsuranceYes
2008-05-01Plan benefit arrangement – General assets of the sponsorYes

Insurance Providers Used on plan

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGVTL0B4L6
Policy instance 7
Insurance contract or identification numberGVTL0B4L6
Number of Individuals Covered54
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $2,828
Total amount of fees paid to insurance companyUSD $1,378
Life Insurance Welfare BenefitYes
Other welfare benefits providedA D & D VOLUNTARY
Welfare Benefit Premiums Paid to CarrierUSD $18,853
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,828
Amount paid for insurance broker fees1378
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGUPR0B4L6
Policy instance 1
Insurance contract or identification numberGUPR0B4L6
Number of Individuals Covered14
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $1,399
Total amount of fees paid to insurance companyUSD $561
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $9,328
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,399
Amount paid for insurance broker fees561
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
HCC LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 92711 )
Policy contract numberHCCLOT40699
Policy instance 2
Insurance contract or identification numberHCCLOT40699
Number of Individuals Covered84
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $935
Other welfare benefits providedTRANSPLANT
Welfare Benefit Premiums Paid to CarrierUSD $11,916
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Amount paid for insurance broker fees935
Additional information about fees paid to insurance brokerOVERRIDE
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGUC0B4L6
Policy instance 3
Insurance contract or identification numberGUC0B4L6
Number of Individuals Covered33
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $2,342
Total amount of fees paid to insurance companyUSD $1,089
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $15,613
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,342
Amount paid for insurance broker fees1089
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number30040262
Policy instance 4
Insurance contract or identification number30040262
Number of Individuals Covered90
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $1,246
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $12,372
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,246
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGUDH0B4L6
Policy instance 5
Insurance contract or identification numberGUDH0B4L6
Number of Individuals Covered28
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $1,407
Total amount of fees paid to insurance companyUSD $604
Other welfare benefits providedACCIDENT VOLUNTARY
Welfare Benefit Premiums Paid to CarrierUSD $9,380
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,407
Amount paid for insurance broker fees604
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGUDE0B4L6
Policy instance 6
Insurance contract or identification numberGUDE0B4L6
Number of Individuals Covered17
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $533
Total amount of fees paid to insurance companyUSD $277
Other welfare benefits providedCRITICAL ILLNESS VOLUNTARY
Welfare Benefit Premiums Paid to CarrierUSD $3,554
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $533
Amount paid for insurance broker fees277
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGUDE0B4L6
Policy instance 1
Insurance contract or identification numberGUDE0B4L6
Number of Individuals Covered20
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $692
Total amount of fees paid to insurance companyUSD $353
Other welfare benefits providedCRITICAL ILLNESS VOLUNTARY
Welfare Benefit Premiums Paid to CarrierUSD $4,613
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $692
Amount paid for insurance broker fees353
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGVTL0B4L6
Policy instance 2
Insurance contract or identification numberGVTL0B4L6
Number of Individuals Covered65
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $3,445
Total amount of fees paid to insurance companyUSD $1,317
Life Insurance Welfare BenefitYes
Other welfare benefits providedA D & D VOLUNTARY
Welfare Benefit Premiums Paid to CarrierUSD $22,966
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,445
Amount paid for insurance broker fees1317
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGUC0B4L6
Policy instance 3
Insurance contract or identification numberGUC0B4L6
Number of Individuals Covered38
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $2,723
Total amount of fees paid to insurance companyUSD $1,100
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $18,156
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,723
Amount paid for insurance broker fees1100
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number30040262
Policy instance 4
Insurance contract or identification number30040262
Number of Individuals Covered106
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $1,575
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $15,436
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,575
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGUDH0B4L6
Policy instance 5
Insurance contract or identification numberGUDH0B4L6
Number of Individuals Covered29
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $1,510
Total amount of fees paid to insurance companyUSD $716
Other welfare benefits providedACCIDENT VOLUNTARY
Welfare Benefit Premiums Paid to CarrierUSD $10,066
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,510
Amount paid for insurance broker fees716
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
HCC LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 92711 )
Policy contract numberHCCLOT40699
Policy instance 6
Insurance contract or identification numberHCCLOT40699
Number of Individuals Covered100
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $617
Other welfare benefits providedTRANSPLANT
Welfare Benefit Premiums Paid to CarrierUSD $12,341
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Amount paid for insurance broker fees617
Additional information about fees paid to insurance brokerOVERRIDE
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGUPR0B4L6
Policy instance 7
Insurance contract or identification numberGUPR0B4L6
Number of Individuals Covered18
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $1,403
Total amount of fees paid to insurance companyUSD $630
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $9,352
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,403
Amount paid for insurance broker fees630
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGUDH0B4L6
Policy instance 1
Insurance contract or identification numberGUDH0B4L6
Number of Individuals Covered30
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $1,678
Total amount of fees paid to insurance companyUSD $506
Other welfare benefits providedACCIDENT VOLUNTARY
Welfare Benefit Premiums Paid to CarrierUSD $11,186
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,678
Amount paid for insurance broker fees506
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
HCC LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 92711 )
Policy contract numberHCCLOT40699
Policy instance 2
Insurance contract or identification numberHCCLOT40699
Number of Individuals Covered113
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $677
Other welfare benefits providedTRANSPLANT
Welfare Benefit Premiums Paid to CarrierUSD $13,571
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Amount paid for insurance broker fees59
Additional information about fees paid to insurance brokerOVERRIDE
Insurance broker organization code?3
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number30040262
Policy instance 3
Insurance contract or identification number30040262
Number of Individuals Covered115
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $1,718
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $16,964
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,718
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGVTL0B4L6
Policy instance 4
Insurance contract or identification numberGVTL0B4L6
Number of Individuals Covered68
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $3,072
Total amount of fees paid to insurance companyUSD $957
Life Insurance Welfare BenefitYes
Other welfare benefits providedA D & D
Welfare Benefit Premiums Paid to CarrierUSD $20,478
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,072
Amount paid for insurance broker fees957
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGUPR0B4L6
Policy instance 5
Insurance contract or identification numberGUPR0B4L6
Number of Individuals Covered20
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $1,468
Total amount of fees paid to insurance companyUSD $432
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $9,785
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,468
Amount paid for insurance broker fees432
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGUDE0B4L6
Policy instance 6
Insurance contract or identification numberGUDE0B4L6
Number of Individuals Covered20
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $824
Total amount of fees paid to insurance companyUSD $261
Other welfare benefits providedCRITICAL ILLNESS VOLUNTARY
Welfare Benefit Premiums Paid to CarrierUSD $5,493
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $824
Amount paid for insurance broker fees261
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGUC0B4L6
Policy instance 7
Insurance contract or identification numberGUC0B4L6
Number of Individuals Covered41
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $2,567
Total amount of fees paid to insurance companyUSD $819
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $17,110
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,567
Amount paid for insurance broker fees819
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLUG0B4L6
Policy instance 8
Insurance contract or identification numberGLUG0B4L6
Number of Individuals Covered0
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $196
Life Insurance Welfare BenefitYes
Other welfare benefits providedA D & D
Welfare Benefit Premiums Paid to CarrierUSD $-14
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $0
Amount paid for insurance broker fees196
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGUDE0B4L6
Policy instance 2
Insurance contract or identification numberGUDE0B4L6
Number of Individuals Covered23
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $710
Total amount of fees paid to insurance companyUSD $262
Other welfare benefits providedCRITICAL ILLNESS VOLUNTARY
Welfare Benefit Premiums Paid to CarrierUSD $4,735
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $710
Amount paid for insurance broker fees262
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number30040262
Policy instance 3
Insurance contract or identification number30040262
Number of Individuals Covered124
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $1,649
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $16,497
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,649
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLUG0B4L6
Policy instance 4
Insurance contract or identification numberGLUG0B4L6
Number of Individuals Covered126
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $535
Total amount of fees paid to insurance companyUSD $165
Life Insurance Welfare BenefitYes
Other welfare benefits providedA D & D
Welfare Benefit Premiums Paid to CarrierUSD $3,563
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $535
Amount paid for insurance broker fees165
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGUDH0B4L6
Policy instance 5
Insurance contract or identification numberGUDH0B4L6
Number of Individuals Covered26
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $1,378
Total amount of fees paid to insurance companyUSD $516
Other welfare benefits providedACCIDENT VOLUNTARY
Welfare Benefit Premiums Paid to CarrierUSD $9,186
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,378
Amount paid for insurance broker fees516
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGUPR0B4L6
Policy instance 6
Insurance contract or identification numberGUPR0B4L6
Number of Individuals Covered20
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $1,186
Total amount of fees paid to insurance companyUSD $563
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $7,905
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,186
Amount paid for insurance broker fees563
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
HCC LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 92711 )
Policy contract numberHCCLOT40699
Policy instance 7
Insurance contract or identification numberHCCLOT40699
Number of Individuals Covered123
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $685
Other welfare benefits providedTRANSPLANT
Welfare Benefit Premiums Paid to CarrierUSD $13,553
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Amount paid for insurance broker fees685
Additional information about fees paid to insurance brokerOVERRIDE
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGUC0B4L6
Policy instance 1
Insurance contract or identification numberGUC0B4L6
Number of Individuals Covered38
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $2,231
Total amount of fees paid to insurance companyUSD $905
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $14,872
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,231
Amount paid for insurance broker fees905
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGVTL0B4L6
Policy instance 8
Insurance contract or identification numberGVTL0B4L6
Number of Individuals Covered62
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $2,614
Total amount of fees paid to insurance companyUSD $885
Life Insurance Welfare BenefitYes
Other welfare benefits providedA D & D
Welfare Benefit Premiums Paid to CarrierUSD $17,427
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,614
Amount paid for insurance broker fees885
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGUPR0B4L6
Policy instance 7
Insurance contract or identification numberGUPR0B4L6
Number of Individuals Covered25
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $1,690
Total amount of fees paid to insurance companyUSD $990
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $11,264
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,690
Amount paid for insurance broker fees990
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLUG0B4L6
Policy instance 1
Insurance contract or identification numberGLUG0B4L6
Number of Individuals Covered105
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $494
Total amount of fees paid to insurance companyUSD $270
Life Insurance Welfare BenefitYes
Other welfare benefits providedA D & D
Welfare Benefit Premiums Paid to CarrierUSD $3,294
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $494
Amount paid for insurance broker fees270
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGUDE0B4L6
Policy instance 2
Insurance contract or identification numberGUDE0B4L6
Number of Individuals Covered33
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $786
Total amount of fees paid to insurance companyUSD $440
Other welfare benefits providedCRITICAL ILLNESS VOLUNTARY
Welfare Benefit Premiums Paid to CarrierUSD $5,240
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $786
Amount paid for insurance broker fees440
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGUDH0B4L6
Policy instance 3
Insurance contract or identification numberGUDH0B4L6
Number of Individuals Covered27
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $1,548
Total amount of fees paid to insurance companyUSD $852
Other welfare benefits providedACCIDENT VOLUNTARY
Welfare Benefit Premiums Paid to CarrierUSD $10,317
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,548
Amount paid for insurance broker fees852
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number30040262
Policy instance 4
Insurance contract or identification number30040262
Number of Individuals Covered98
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $1,594
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $15,938
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,594
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGVTL0B4L6
Policy instance 5
Insurance contract or identification numberGVTL0B4L6
Number of Individuals Covered56
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $2,655
Total amount of fees paid to insurance companyUSD $1,500
Life Insurance Welfare BenefitYes
Other welfare benefits providedA D & D
Welfare Benefit Premiums Paid to CarrierUSD $17,702
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,655
Amount paid for insurance broker fees1500
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGUC0B4L6
Policy instance 6
Insurance contract or identification numberGUC0B4L6
Number of Individuals Covered43
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $2,714
Total amount of fees paid to insurance companyUSD $1,650
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $18,093
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,714
Amount paid for insurance broker fees1650
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGUPR0B4L6
Policy instance 1
Insurance contract or identification numberGUPR0B4L6
Number of Individuals Covered35
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $1,900
Total amount of fees paid to insurance companyUSD $0
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $12,670
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,900
Insurance broker organization code?3
Insurance broker nameMARSH AND MCLENNAN AGENCY LLC
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGUDH0B4L6
Policy instance 2
Insurance contract or identification numberGUDH0B4L6
Number of Individuals Covered33
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $1,709
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedACCIDENT VOLUNTARY
Welfare Benefit Premiums Paid to CarrierUSD $11,396
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,709
Insurance broker organization code?3
Insurance broker nameMARSH AND MCLENNAN AGENCY LLC
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLUG0B4L6
Policy instance 3
Insurance contract or identification numberGLUG0B4L6
Number of Individuals Covered122
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $535
Total amount of fees paid to insurance companyUSD $0
Life Insurance Welfare BenefitYes
Other welfare benefits providedA D & D
Welfare Benefit Premiums Paid to CarrierUSD $3,567
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $535
Insurance broker organization code?3
Insurance broker nameMARSH AND MCLENNAN AGENCY LLC
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGUC0B4L6
Policy instance 4
Insurance contract or identification numberGUC0B4L6
Number of Individuals Covered53
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $3,213
Total amount of fees paid to insurance companyUSD $0
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $21,420
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,213
Insurance broker organization code?3
Insurance broker nameMARSH AND MCLENNAN AGENCY LLC
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGUDE0B4L6
Policy instance 5
Insurance contract or identification numberGUDE0B4L6
Number of Individuals Covered39
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $796
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedCRITICAL ILLNESS VOLUNTARY
Welfare Benefit Premiums Paid to CarrierUSD $5,307
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $796
Insurance broker organization code?3
Insurance broker nameMARSH AND MCLENNAN AGENCY LLC
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number30040262
Policy instance 6
Insurance contract or identification number30040262
Number of Individuals Covered114
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $1,624
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $16,244
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,624
Insurance broker organization code?3
Insurance broker nameMARSH & MCLELLAN AGENCY LLC
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGVTL0B4L6
Policy instance 7
Insurance contract or identification numberGVTL0B4L6
Number of Individuals Covered70
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $2,771
Life Insurance Welfare BenefitYes
Other welfare benefits providedA D & D
Welfare Benefit Premiums Paid to CarrierUSD $18,476
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,771
Insurance broker organization code?3
Insurance broker nameMARSH AND MCLENNAN AGENCY LLC
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number30040262
Policy instance 1
Insurance contract or identification number30040262
Number of Individuals Covered119
Insurance policy start date2015-05-01
Insurance policy end date2016-04-30
Total amount of commissions paid to insurance brokerUSD $272
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $17,645
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $272
Insurance broker organization code?3
Insurance broker nameMARSH & MCLELLAN AGENCY LLC
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract numberR0539585
Policy instance 4
Insurance contract or identification numberR0539585
Number of Individuals Covered74
Insurance policy start date2015-05-01
Insurance policy end date2016-04-30
Total amount of commissions paid to insurance brokerUSD $3,219
Total amount of fees paid to insurance companyUSD $249
Other welfare benefits providedCRITICAL ILLNESS, ACCIDENTAL, HOSPITAL
Welfare Benefit Premiums Paid to CarrierUSD $16,826
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,286
Amount paid for insurance broker fees104
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION PAID
Insurance broker organization code?3
Insurance broker nameDAVIS ALLEN AGENCY INC
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number297659
Policy instance 3
Insurance contract or identification number297659
Number of Individuals Covered125
Insurance policy start date2015-05-01
Insurance policy end date2016-04-30
Total amount of commissions paid to insurance brokerUSD $827
Total amount of fees paid to insurance companyUSD $72
Life Insurance Welfare BenefitYes
Other welfare benefits providedA D & D
Welfare Benefit Premiums Paid to CarrierUSD $4,135
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $827
Amount paid for insurance broker fees72
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION PAID
Insurance broker organization code?3
Insurance broker nameMARSH & MCLENNAN AGENCY LLC
PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )
Policy contract number0010205348
Policy instance 2
Insurance contract or identification number0010205348
Number of Individuals Covered42
Insurance policy start date2015-05-01
Insurance policy end date2016-04-30
Total amount of commissions paid to insurance brokerUSD $2,453
Total amount of fees paid to insurance companyUSD $66
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $15,656
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,472
Insurance broker organization code?3
Amount paid for insurance broker fees30
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION PAID
Insurance broker nameC2 CENTRIC LLC
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number30040262
Policy instance 1
Insurance contract or identification number30040262
Number of Individuals Covered119
Insurance policy start date2014-05-01
Insurance policy end date2015-04-30
Total amount of commissions paid to insurance brokerUSD $1,549
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $15,495
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 nameMC & H LIFE AGENCY, INC
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number467078
Policy instance 2
Insurance contract or identification number467078
Number of Individuals Covered81
Insurance policy start date2014-05-01
Insurance policy end date2015-04-30
Total amount of commissions paid to insurance brokerUSD $2,268
Total amount of fees paid to insurance companyUSD $605
Life Insurance Welfare BenefitYes
Other welfare benefits providedLIFESTYLE A D & D
Welfare Benefit Premiums Paid to CarrierUSD $15,122
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,268
Amount paid for insurance broker fees605
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION PAID
Insurance broker organization code?3
Insurance broker nameMC & H LIFE INSURANCE AGENCY INC
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number297659
Policy instance 3
Insurance contract or identification number297659
Number of Individuals Covered129
Insurance policy start date2014-05-01
Insurance policy end date2015-04-30
Total amount of commissions paid to insurance brokerUSD $985
Total amount of fees paid to insurance companyUSD $86
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
Other welfare benefits providedA D & 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 $4,609
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $985
Amount paid for insurance broker fees86
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION PAID
Insurance broker organization code?3
Insurance broker nameMC & H LIFE INSURANCE AGENCY INC
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number297659
Policy instance 2
Insurance contract or identification number297659
Number of Individuals Covered113
Insurance policy start date2013-05-01
Insurance policy end date2014-04-30
Total amount of commissions paid to insurance brokerUSD $766
Total amount of fees paid to insurance companyUSD $53
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
Other welfare benefits providedA D & 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 $4,146
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $766
Amount paid for insurance broker fees53
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION PAID
Insurance broker organization code?3
Insurance broker nameMC & H LIFE INSURANCE AGENCY INC
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number30040262
Policy instance 1
Insurance contract or identification number30040262
Number of Individuals Covered104
Insurance policy start date2013-01-01
Insurance policy end date2013-12-31
Total amount of commissions paid to insurance brokerUSD $858
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 $8,583
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $858
Insurance broker organization code?3
Insurance broker nameMC & H LIFE AGENCY, INC
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number000000297659
Policy instance 1
Insurance contract or identification number000000297659
Number of Individuals Covered122
Insurance policy start date2012-05-01
Insurance policy end date2013-04-30
Total amount of commissions paid to insurance brokerUSD $1,334
Total amount of fees paid to insurance companyUSD $41
Life Insurance Welfare BenefitYes
Other welfare benefits providedA D & D
Welfare Benefit Premiums Paid to CarrierUSD $3,043
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $559
Insurance broker organization code?3
Amount paid for insurance broker fees41
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION PAID
Insurance broker nameMC & H LIFE INSURANCE AGENCY INC
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number000000297659
Policy instance 1
Insurance contract or identification number000000297659
Number of Individuals Covered126
Insurance policy start date2011-05-01
Insurance policy end date2012-04-30
Total amount of commissions paid to insurance brokerUSD $682
Life Insurance Welfare BenefitYes
Other welfare benefits providedA D & D
Welfare Benefit Premiums Paid to CarrierUSD $3,679
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
AMERICAN UNITED LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60895 )
Policy contract numberG 00609268
Policy instance 2
Insurance contract or identification numberG 00609268
Insurance policy start date2011-05-01
Insurance policy end date2012-04-30
Life Insurance Welfare BenefitYes
Other welfare benefits providedA D & D
AMERICAN UNITED LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60895 )
Policy contract numberG 00609268
Policy instance 1
Insurance contract or identification numberG 00609268
Number of Individuals Covered131
Insurance policy start date2010-05-01
Insurance policy end date2011-04-30
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Life Insurance Welfare BenefitYes
Other welfare benefits providedA D & D
Welfare Benefit Premiums Paid to CarrierUSD $4,630
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
AMERICAN UNITED LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60895 )
Policy contract numberG 00609268
Policy instance 1
Insurance contract or identification numberG 00609268
Number of Individuals Covered109
Insurance policy start date2009-05-01
Insurance policy end date2010-04-30
Total amount of commissions paid to insurance brokerUSD $1,065
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 BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedA D & 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 $5,323
Commission paid to Insurance BrokerUSD $1,065
Insurance broker organization code?3
Insurance broker namePROVIDENCE ADMINISTRATIVE SERVICES
AMERICAN UNITED LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60895 )
Policy contract numberG 00609268
Policy instance 1
Insurance contract or identification numberG 00609268
Number of Individuals Covered0
Insurance policy start date2008-05-01
Insurance policy end date2009-04-30
Total amount of commissions paid to insurance brokerUSD $0
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 BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedA D & D
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?Yes

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