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HYUNDAI AUTOEVER AMERICA, LLC EMPLOYEE BENEFITS PLAN 401k Plan overview

Plan NameHYUNDAI AUTOEVER AMERICA, LLC EMPLOYEE BENEFITS PLAN
Plan identification number 503

HYUNDAI AUTOEVER AMERICA, LLC EMPLOYEE BENEFITS PLAN Benefits

401k Plan TypeWelfare Benefit
Plan Features/Benefits
  • Health (other than dental or vision)
  • Life insurance
  • Dental
  • Vision
  • Temporary disability (accident and sickness)
  • Long-term disability cover
  • Other welfare benefit cover

401k Sponsoring company profile

HYUNDAI AUTOEVER AMERICA, LLC has sponsored the creation of one or more 401k plans.

Company Name:HYUNDAI AUTOEVER AMERICA, LLC
Employer identification number (EIN):510531094
NAIC Classification:541519
NAIC Description:Other Computer Related Services

Form 5500 Filing Information

Submission information for form 5500 for 401k plan HYUNDAI AUTOEVER AMERICA, LLC EMPLOYEE BENEFITS PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5032021-11-01
5032020-11-01
5032019-11-01
5032018-11-01
5032017-11-01
5032016-11-01JOELLEN WHITEWOLF JOELLEN WHITEWOLF2018-03-16
5032015-11-01JOELLEN PISANO JOELLEN PISANO2017-04-19
5032014-11-01JOELLEN PISANO JOELLEN PISANO2016-03-16
5032013-11-01JOELLEN PISANO
5032012-11-01JOELLEN PISANO
5032011-11-01JOELLEN PISANO
5032010-11-01JOELLEN PISANO
5032009-11-01JOELLEN PISANO
5032008-11-01JOELLEN PISANO
5032007-11-01JOELLEN PISANO

Plan Statistics for HYUNDAI AUTOEVER AMERICA, LLC EMPLOYEE BENEFITS PLAN

401k plan membership statisitcs for HYUNDAI AUTOEVER AMERICA, LLC EMPLOYEE BENEFITS PLAN

Measure Date Value
2021: HYUNDAI AUTOEVER AMERICA, LLC EMPLOYEE BENEFITS PLAN 2021 401k membership
Total participants, beginning-of-year2021-11-01276
Total number of active participants reported on line 7a of the Form 55002021-11-01296
Number of retired or separated participants receiving benefits2021-11-013
Number of other retired or separated participants entitled to future benefits2021-11-010
Total of all active and inactive participants2021-11-01299
2020: HYUNDAI AUTOEVER AMERICA, LLC EMPLOYEE BENEFITS PLAN 2020 401k membership
Total participants, beginning-of-year2020-11-01343
Total number of active participants reported on line 7a of the Form 55002020-11-01268
Number of retired or separated participants receiving benefits2020-11-018
Number of other retired or separated participants entitled to future benefits2020-11-010
Total of all active and inactive participants2020-11-01276
2019: HYUNDAI AUTOEVER AMERICA, LLC EMPLOYEE BENEFITS PLAN 2019 401k membership
Total participants, beginning-of-year2019-11-01343
Total number of active participants reported on line 7a of the Form 55002019-11-01246
Total of all active and inactive participants2019-11-01246
2018: HYUNDAI AUTOEVER AMERICA, LLC EMPLOYEE BENEFITS PLAN 2018 401k membership
Total participants, beginning-of-year2018-11-01324
Total number of active participants reported on line 7a of the Form 55002018-11-01343
Number of retired or separated participants receiving benefits2018-11-019
Number of other retired or separated participants entitled to future benefits2018-11-010
Total of all active and inactive participants2018-11-01352
2017: HYUNDAI AUTOEVER AMERICA, LLC EMPLOYEE BENEFITS PLAN 2017 401k membership
Total participants, beginning-of-year2017-11-01300
Total number of active participants reported on line 7a of the Form 55002017-11-01317
Number of retired or separated participants receiving benefits2017-11-017
Number of other retired or separated participants entitled to future benefits2017-11-010
Total of all active and inactive participants2017-11-01324
2016: HYUNDAI AUTOEVER AMERICA, LLC EMPLOYEE BENEFITS PLAN 2016 401k membership
Total participants, beginning-of-year2016-11-01297
Total number of active participants reported on line 7a of the Form 55002016-11-01297
Number of retired or separated participants receiving benefits2016-11-013
Number of other retired or separated participants entitled to future benefits2016-11-010
Total of all active and inactive participants2016-11-01300
2015: HYUNDAI AUTOEVER AMERICA, LLC EMPLOYEE BENEFITS PLAN 2015 401k membership
Total participants, beginning-of-year2015-11-01315
Total number of active participants reported on line 7a of the Form 55002015-11-01295
Number of retired or separated participants receiving benefits2015-11-012
Number of other retired or separated participants entitled to future benefits2015-11-010
Total of all active and inactive participants2015-11-01297
2014: HYUNDAI AUTOEVER AMERICA, LLC EMPLOYEE BENEFITS PLAN 2014 401k membership
Total participants, beginning-of-year2014-11-01308
Total number of active participants reported on line 7a of the Form 55002014-11-01314
Number of retired or separated participants receiving benefits2014-11-011
Number of other retired or separated participants entitled to future benefits2014-11-010
Total of all active and inactive participants2014-11-01315
2013: HYUNDAI AUTOEVER AMERICA, LLC EMPLOYEE BENEFITS PLAN 2013 401k membership
Total participants, beginning-of-year2013-11-01250
Total number of active participants reported on line 7a of the Form 55002013-11-01303
Number of retired or separated participants receiving benefits2013-11-010
Number of other retired or separated participants entitled to future benefits2013-11-010
Total of all active and inactive participants2013-11-01303
2012: HYUNDAI AUTOEVER AMERICA, LLC EMPLOYEE BENEFITS PLAN 2012 401k membership
Total participants, beginning-of-year2012-11-01281
Total number of active participants reported on line 7a of the Form 55002012-11-01346
Number of retired or separated participants receiving benefits2012-11-010
Number of other retired or separated participants entitled to future benefits2012-11-010
Total of all active and inactive participants2012-11-01346
2011: HYUNDAI AUTOEVER AMERICA, LLC EMPLOYEE BENEFITS PLAN 2011 401k membership
Total participants, beginning-of-year2011-11-01228
Total number of active participants reported on line 7a of the Form 55002011-11-01265
Number of retired or separated participants receiving benefits2011-11-010
Number of other retired or separated participants entitled to future benefits2011-11-010
Total of all active and inactive participants2011-11-01265
2010: HYUNDAI AUTOEVER AMERICA, LLC EMPLOYEE BENEFITS PLAN 2010 401k membership
Total participants, beginning-of-year2010-11-01206
Total number of active participants reported on line 7a of the Form 55002010-11-01228
Number of retired or separated participants receiving benefits2010-11-010
Number of other retired or separated participants entitled to future benefits2010-11-010
Total of all active and inactive participants2010-11-01228
2009: HYUNDAI AUTOEVER AMERICA, LLC EMPLOYEE BENEFITS PLAN 2009 401k membership
Total participants, beginning-of-year2009-11-01199
Total number of active participants reported on line 7a of the Form 55002009-11-01206
Number of retired or separated participants receiving benefits2009-11-010
Number of other retired or separated participants entitled to future benefits2009-11-010
Total of all active and inactive participants2009-11-01206
2008: HYUNDAI AUTOEVER AMERICA, LLC EMPLOYEE BENEFITS PLAN 2008 401k membership
Total participants, beginning-of-year2008-11-01166
Total number of active participants reported on line 7a of the Form 55002008-11-01199
Number of retired or separated participants receiving benefits2008-11-010
Number of other retired or separated participants entitled to future benefits2008-11-010
Total of all active and inactive participants2008-11-01199
2007: HYUNDAI AUTOEVER AMERICA, LLC EMPLOYEE BENEFITS PLAN 2007 401k membership
Total participants, beginning-of-year2007-11-01138
Total number of active participants reported on line 7a of the Form 55002007-11-01166
Number of retired or separated participants receiving benefits2007-11-010
Number of other retired or separated participants entitled to future benefits2007-11-010
Total of all active and inactive participants2007-11-01166

Form 5500 Responses for HYUNDAI AUTOEVER AMERICA, LLC EMPLOYEE BENEFITS PLAN

2021: HYUNDAI AUTOEVER AMERICA, LLC EMPLOYEE BENEFITS PLAN 2021 form 5500 responses
2021-11-01Type of plan entitySingle employer plan
2021-11-01Submission has been amendedNo
2021-11-01This submission is the final filingNo
2021-11-01This return/report is a short plan year return/report (less than 12 months)No
2021-11-01Plan is a collectively bargained planNo
2021-11-01Plan funding arrangement – General assets of the sponsorYes
2021-11-01Plan benefit arrangement – InsuranceYes
2021-11-01Plan benefit arrangement – General assets of the sponsorYes
2020: HYUNDAI AUTOEVER AMERICA, LLC EMPLOYEE BENEFITS PLAN 2020 form 5500 responses
2020-11-01Type of plan entitySingle employer plan
2020-11-01Submission has been amendedNo
2020-11-01This submission is the final filingNo
2020-11-01This return/report is a short plan year return/report (less than 12 months)No
2020-11-01Plan is a collectively bargained planNo
2020-11-01Plan funding arrangement – General assets of the sponsorYes
2020-11-01Plan benefit arrangement – InsuranceYes
2020-11-01Plan benefit arrangement – General assets of the sponsorYes
2019: HYUNDAI AUTOEVER AMERICA, LLC EMPLOYEE BENEFITS PLAN 2019 form 5500 responses
2019-11-01Type of plan entitySingle employer plan
2019-11-01Submission has been amendedNo
2019-11-01This submission is the final filingNo
2019-11-01This return/report is a short plan year return/report (less than 12 months)No
2019-11-01Plan is a collectively bargained planNo
2019-11-01Plan funding arrangement – General assets of the sponsorYes
2019-11-01Plan benefit arrangement – InsuranceYes
2019-11-01Plan benefit arrangement – General assets of the sponsorYes
2018: HYUNDAI AUTOEVER AMERICA, LLC EMPLOYEE BENEFITS PLAN 2018 form 5500 responses
2018-11-01Type of plan entitySingle employer plan
2018-11-01Submission has been amendedNo
2018-11-01This submission is the final filingNo
2018-11-01This return/report is a short plan year return/report (less than 12 months)No
2018-11-01Plan is a collectively bargained planNo
2018-11-01Plan funding arrangement – General assets of the sponsorYes
2018-11-01Plan benefit arrangement – InsuranceYes
2018-11-01Plan benefit arrangement – General assets of the sponsorYes
2017: HYUNDAI AUTOEVER AMERICA, LLC EMPLOYEE BENEFITS PLAN 2017 form 5500 responses
2017-11-01Type of plan entitySingle employer plan
2017-11-01Submission has been amendedNo
2017-11-01This submission is the final filingNo
2017-11-01This return/report is a short plan year return/report (less than 12 months)No
2017-11-01Plan is a collectively bargained planNo
2017-11-01Plan funding arrangement – InsuranceYes
2017-11-01Plan funding arrangement – General assets of the sponsorYes
2017-11-01Plan benefit arrangement – InsuranceYes
2017-11-01Plan benefit arrangement – General assets of the sponsorYes
2016: HYUNDAI AUTOEVER AMERICA, LLC EMPLOYEE BENEFITS PLAN 2016 form 5500 responses
2016-11-01Type of plan entitySingle employer plan
2016-11-01Submission has been amendedNo
2016-11-01This submission is the final filingNo
2016-11-01This return/report is a short plan year return/report (less than 12 months)No
2016-11-01Plan is a collectively bargained planNo
2016-11-01Plan funding arrangement – InsuranceYes
2016-11-01Plan funding arrangement – General assets of the sponsorYes
2016-11-01Plan benefit arrangement – InsuranceYes
2016-11-01Plan benefit arrangement – General assets of the sponsorYes
2015: HYUNDAI AUTOEVER AMERICA, LLC EMPLOYEE BENEFITS PLAN 2015 form 5500 responses
2015-11-01Type of plan entitySingle employer plan
2015-11-01Submission has been amendedNo
2015-11-01This submission is the final filingNo
2015-11-01This return/report is a short plan year return/report (less than 12 months)No
2015-11-01Plan is a collectively bargained planNo
2015-11-01Plan funding arrangement – InsuranceYes
2015-11-01Plan funding arrangement – General assets of the sponsorYes
2015-11-01Plan benefit arrangement – InsuranceYes
2015-11-01Plan benefit arrangement – General assets of the sponsorYes
2014: HYUNDAI AUTOEVER AMERICA, LLC EMPLOYEE BENEFITS PLAN 2014 form 5500 responses
2014-11-01Type of plan entitySingle employer plan
2014-11-01Submission has been amendedNo
2014-11-01This submission is the final filingNo
2014-11-01This return/report is a short plan year return/report (less than 12 months)No
2014-11-01Plan is a collectively bargained planNo
2014-11-01Plan funding arrangement – InsuranceYes
2014-11-01Plan funding arrangement – General assets of the sponsorYes
2014-11-01Plan benefit arrangement – InsuranceYes
2014-11-01Plan benefit arrangement – General assets of the sponsorYes
2013: HYUNDAI AUTOEVER AMERICA, LLC EMPLOYEE BENEFITS PLAN 2013 form 5500 responses
2013-11-01Type of plan entitySingle employer plan
2013-11-01Submission has been amendedNo
2013-11-01This submission is the final filingNo
2013-11-01This return/report is a short plan year return/report (less than 12 months)No
2013-11-01Plan is a collectively bargained planNo
2013-11-01Plan funding arrangement – InsuranceYes
2013-11-01Plan funding arrangement – General assets of the sponsorYes
2013-11-01Plan benefit arrangement – InsuranceYes
2013-11-01Plan benefit arrangement – General assets of the sponsorYes
2012: HYUNDAI AUTOEVER AMERICA, LLC EMPLOYEE BENEFITS PLAN 2012 form 5500 responses
2012-11-01Type of plan entitySingle employer plan
2012-11-01Submission has been amendedNo
2012-11-01This submission is the final filingNo
2012-11-01This return/report is a short plan year return/report (less than 12 months)No
2012-11-01Plan is a collectively bargained planNo
2012-11-01Plan funding arrangement – InsuranceYes
2012-11-01Plan funding arrangement – General assets of the sponsorYes
2012-11-01Plan benefit arrangement – InsuranceYes
2012-11-01Plan benefit arrangement – General assets of the sponsorYes
2011: HYUNDAI AUTOEVER AMERICA, LLC EMPLOYEE BENEFITS PLAN 2011 form 5500 responses
2011-11-01Type of plan entitySingle employer plan
2011-11-01Submission has been amendedNo
2011-11-01This submission is the final filingNo
2011-11-01This return/report is a short plan year return/report (less than 12 months)No
2011-11-01Plan is a collectively bargained planNo
2011-11-01Plan funding arrangement – InsuranceYes
2011-11-01Plan funding arrangement – General assets of the sponsorYes
2011-11-01Plan benefit arrangement – InsuranceYes
2011-11-01Plan benefit arrangement – General assets of the sponsorYes
2010: HYUNDAI AUTOEVER AMERICA, LLC EMPLOYEE BENEFITS PLAN 2010 form 5500 responses
2010-11-01Type of plan entitySingle employer plan
2010-11-01Submission has been amendedNo
2010-11-01This submission is the final filingNo
2010-11-01This return/report is a short plan year return/report (less than 12 months)No
2010-11-01Plan is a collectively bargained planNo
2010-11-01Plan funding arrangement – InsuranceYes
2010-11-01Plan funding arrangement – General assets of the sponsorYes
2010-11-01Plan benefit arrangement – InsuranceYes
2010-11-01Plan benefit arrangement – General assets of the sponsorYes
2009: HYUNDAI AUTOEVER AMERICA, LLC EMPLOYEE BENEFITS PLAN 2009 form 5500 responses
2009-11-01Type of plan entitySingle employer plan
2009-11-01Submission has been amendedNo
2009-11-01This submission is the final filingNo
2009-11-01This return/report is a short plan year return/report (less than 12 months)No
2009-11-01Plan is a collectively bargained planNo
2009-11-01Plan funding arrangement – InsuranceYes
2009-11-01Plan funding arrangement – General assets of the sponsorYes
2009-11-01Plan benefit arrangement – InsuranceYes
2009-11-01Plan benefit arrangement – General assets of the sponsorYes
2008: HYUNDAI AUTOEVER AMERICA, LLC EMPLOYEE BENEFITS PLAN 2008 form 5500 responses
2008-11-01Type of plan entitySingle employer plan
2008-11-01Submission has been amendedNo
2008-11-01This submission is the final filingNo
2008-11-01This return/report is a short plan year return/report (less than 12 months)No
2008-11-01Plan is a collectively bargained planNo
2008-11-01Plan funding arrangement – InsuranceYes
2008-11-01Plan funding arrangement – General assets of the sponsorYes
2008-11-01Plan benefit arrangement – InsuranceYes
2008-11-01Plan benefit arrangement – General assets of the sponsorYes
2007: HYUNDAI AUTOEVER AMERICA, LLC EMPLOYEE BENEFITS PLAN 2007 form 5500 responses
2007-11-01Type of plan entitySingle employer plan
2007-11-01Submission has been amendedNo
2007-11-01This submission is the final filingNo
2007-11-01This return/report is a short plan year return/report (less than 12 months)No
2007-11-01Plan is a collectively bargained planNo
2007-11-01Plan funding arrangement – InsuranceYes
2007-11-01Plan funding arrangement – General assets of the sponsorYes
2007-11-01Plan benefit arrangement – InsuranceYes
2007-11-01Plan benefit arrangement – General assets of the sponsorYes

Insurance Providers Used on plan

CIGNA HEALTHCARE OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number3336474
Policy instance 8
Insurance contract or identification number3336474
Number of Individuals Covered182
Insurance policy start date2021-11-01
Insurance policy end date2022-10-31
Total amount of commissions paid to insurance brokerUSD $8,934
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $8,934
Insurance broker organization code?3
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number30037706
Policy instance 1
Insurance contract or identification number30037706
Number of Individuals Covered292
Insurance policy start date2021-11-01
Insurance policy end date2022-10-31
Total amount of commissions paid to insurance brokerUSD $904
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $45,180
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $455
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberLK963534
Policy instance 2
Insurance contract or identification numberLK963534
Number of Individuals Covered296
Insurance policy start date2020-11-01
Insurance policy end date2021-10-31
Total amount of commissions paid to insurance brokerUSD $1,532
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $15,321
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,532
Insurance broker organization code?3
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number3336474
Policy instance 3
Insurance contract or identification number3336474
Number of Individuals Covered724
Insurance policy start date2021-11-01
Insurance policy end date2022-10-31
Total amount of commissions paid to insurance brokerUSD $115,903
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $1,429,137
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $59,763
Insurance broker organization code?3
BLUE CROSS BLUE SHIELD OF ALABAMA (National Association of Insurance Commissioners NAIC id number: 55433 )
Policy contract number75070
Policy instance 4
Insurance contract or identification number75070
Number of Individuals Covered50
Insurance policy start date2021-11-01
Insurance policy end date2022-10-31
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberOK966692
Policy instance 5
Insurance contract or identification numberOK966692
Number of Individuals Covered296
Insurance policy start date2021-11-01
Insurance policy end date2022-10-31
Total amount of commissions paid to insurance brokerUSD $516
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH & DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $5,160
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $516
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberLK751266
Policy instance 6
Insurance contract or identification numberLK751266
Number of Individuals Covered296
Insurance policy start date2021-11-01
Insurance policy end date2022-10-31
Total amount of commissions paid to insurance brokerUSD $327
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $3,268
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $327
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberFLX965091
Policy instance 7
Insurance contract or identification numberFLX965091
Number of Individuals Covered296
Insurance policy start date2021-11-01
Insurance policy end date2022-10-31
Total amount of commissions paid to insurance brokerUSD $3,197
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 $31,966
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,197
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberLK751266
Policy instance 1
Insurance contract or identification numberLK751266
Number of Individuals Covered289
Insurance policy start date2020-11-01
Insurance policy end date2021-10-31
Total amount of commissions paid to insurance brokerUSD $1,298
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitYes
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 $12,977
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,298
Insurance broker organization code?3
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number30037706
Policy instance 2
Insurance contract or identification number30037706
Number of Individuals Covered296
Insurance policy start date2020-11-01
Insurance policy end date2021-10-31
Total amount of commissions paid to insurance brokerUSD $904
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $45,216
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $904
Insurance broker organization code?3
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number3336474
Policy instance 3
Insurance contract or identification number3336474
Number of Individuals Covered888
Insurance policy start date2020-11-01
Insurance policy end date2021-10-31
Total amount of commissions paid to insurance brokerUSD $119,611
Total amount of fees paid to insurance companyUSD $8,036
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $1,367,813
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $119,611
Amount paid for insurance broker fees8036
Additional information about fees paid to insurance brokerSERVICE/GENERAL AGENT FEES
Insurance broker organization code?3
BLUE CROSS BLUE SHIELD OF ALABAMA (National Association of Insurance Commissioners NAIC id number: 55433 )
Policy contract number75070
Policy instance 4
Insurance contract or identification number75070
Number of Individuals Covered53
Insurance policy start date2020-11-01
Insurance policy end date2021-10-31
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberFLX965091
Policy instance 5
Insurance contract or identification numberFLX965091
Number of Individuals Covered289
Insurance policy start date2020-11-01
Insurance policy end date2021-10-31
Total amount of commissions paid to insurance brokerUSD $12,124
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $121,243
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $12,124
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberLK963534
Policy instance 6
Insurance contract or identification numberLK963534
Number of Individuals Covered289
Insurance policy start date2019-11-01
Insurance policy end date2020-10-31
Total amount of commissions paid to insurance brokerUSD $5,970
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $59,698
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,970
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberOK966692
Policy instance 7
Insurance contract or identification numberOK966692
Number of Individuals Covered289
Insurance policy start date2020-11-01
Insurance policy end date2021-10-31
Total amount of commissions paid to insurance brokerUSD $2,678
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH & DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $26,784
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,678
Insurance broker organization code?3
CIGNA HEALTHCARE OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number3336474
Policy instance 8
Insurance contract or identification number3336474
Number of Individuals Covered189
Insurance policy start date2020-11-01
Insurance policy end date2021-10-31
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number30037706
Policy instance 8
Insurance contract or identification number30037706
Number of Individuals Covered299
Insurance policy start date2019-11-01
Insurance policy end date2020-10-31
Total amount of commissions paid to insurance brokerUSD $997
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $49,126
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $997
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberLK751266
Policy instance 7
Insurance contract or identification numberLK751266
Number of Individuals Covered246
Insurance policy start date2019-11-01
Insurance policy end date2020-10-31
Total amount of commissions paid to insurance brokerUSD $1,114
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitYes
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 $11,137
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,114
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberLK963534
Policy instance 6
Insurance contract or identification numberLK963534
Number of Individuals Covered246
Insurance policy start date2019-11-01
Insurance policy end date2020-10-31
Total amount of commissions paid to insurance brokerUSD $5,095
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $50,950
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,095
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberFLX965091
Policy instance 5
Insurance contract or identification numberFLX965091
Number of Individuals Covered329
Insurance policy start date2019-11-01
Insurance policy end date2020-10-31
Total amount of commissions paid to insurance brokerUSD $12,716
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 $127,160
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $12,716
Insurance broker organization code?3
CIGNA HEALTHCARE OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number3336474
Policy instance 4
Insurance contract or identification number3336474
Number of Individuals Covered192
Insurance policy start date2019-11-01
Insurance policy end date2020-10-31
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?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number3336474
Policy instance 3
Insurance contract or identification number3336474
Number of Individuals Covered931
Insurance policy start date2019-11-01
Insurance policy end date2020-10-31
Total amount of commissions paid to insurance brokerUSD $138,795
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $1,394,596
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $138,802
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberOK966692
Policy instance 2
Insurance contract or identification numberOK966692
Number of Individuals Covered329
Insurance policy start date2019-11-01
Insurance policy end date2020-10-31
Total amount of commissions paid to insurance brokerUSD $1,403
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH & DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $14,030
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,403
Insurance broker organization code?3
BLUE CROSS BLUE SHIELD OF ALABAMA (National Association of Insurance Commissioners NAIC id number: 55433 )
Policy contract number75070
Policy instance 1
Insurance contract or identification number75070
Number of Individuals Covered158
Insurance policy start date2019-11-01
Insurance policy end date2020-10-31
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?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number30037706
Policy instance 2
Insurance contract or identification number30037706
Number of Individuals Covered348
Insurance policy start date2018-11-01
Insurance policy end date2019-10-31
Total amount of commissions paid to insurance brokerUSD $887
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $48,735
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $887
Insurance broker organization code?3
CIGNA HEALTHCARE OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number3336474
Policy instance 1
Insurance contract or identification number3336474
Number of Individuals Covered206
Insurance policy start date2018-11-01
Insurance policy end date2019-10-31
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberFLX965091
Policy instance 3
Insurance contract or identification numberFLX965091
Number of Individuals Covered343
Insurance policy start date2018-11-01
Insurance policy end date2019-10-31
Total amount of commissions paid to insurance brokerUSD $13,720
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 $137,204
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $13,720
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberOK966692
Policy instance 4
Insurance contract or identification numberOK966692
Number of Individuals Covered343
Insurance policy start date2018-11-01
Insurance policy end date2019-10-31
Total amount of commissions paid to insurance brokerUSD $1,754
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH & DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $17,542
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,754
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberLK963534
Policy instance 5
Insurance contract or identification numberLK963534
Number of Individuals Covered343
Insurance policy start date2018-11-01
Insurance policy end date2019-10-31
Total amount of commissions paid to insurance brokerUSD $6,469
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $64,694
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6,469
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberLK751266
Policy instance 6
Insurance contract or identification numberLK751266
Number of Individuals Covered343
Insurance policy start date2018-11-01
Insurance policy end date2019-10-31
Total amount of commissions paid to insurance brokerUSD $1,454
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitYes
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 $14,543
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,454
Insurance broker organization code?3
BLUE CROSS BLUE SHIELD OF ALABAMA (National Association of Insurance Commissioners NAIC id number: 55433 )
Policy contract number75070
Policy instance 7
Insurance contract or identification number75070
Number of Individuals Covered64
Insurance policy start date2018-11-01
Insurance policy end date2019-10-31
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
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 number3336474
Policy instance 8
Insurance contract or identification number3336474
Number of Individuals Covered1062
Insurance policy start date2018-11-01
Insurance policy end date2019-10-31
Total amount of commissions paid to insurance brokerUSD $106,648
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $1,421,514
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $106,648
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberFLX965091
Policy instance 2
Insurance contract or identification numberFLX965091
Number of Individuals Covered317
Insurance policy start date2017-11-01
Insurance policy end date2018-10-31
Total amount of commissions paid to insurance brokerUSD $14,001
Total amount of fees paid to insurance companyUSD $2,560
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $140,010
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberLK 963534
Policy instance 3
Insurance contract or identification numberLK 963534
Number of Individuals Covered317
Insurance policy start date2017-11-01
Insurance policy end date2018-10-31
Total amount of commissions paid to insurance brokerUSD $6,008
Total amount of fees paid to insurance companyUSD $981
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $60,082
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
CIGNA HEALTHCARE OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number3336474
Policy instance 4
Insurance contract or identification number3336474
Number of Individuals Covered179
Insurance policy start date2017-11-01
Insurance policy end date2018-10-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberOK 966692
Policy instance 5
Insurance contract or identification numberOK 966692
Number of Individuals Covered317
Insurance policy start date2017-11-01
Insurance policy end date2018-10-31
Total amount of commissions paid to insurance brokerUSD $1,690
Total amount of fees paid to insurance companyUSD $315
Other welfare benefits providedACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $16,897
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number30037706
Policy instance 6
Insurance contract or identification number30037706
Number of Individuals Covered319
Insurance policy start date2017-11-01
Insurance policy end date2018-10-31
Total amount of commissions paid to insurance brokerUSD $908
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $45,385
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 number3336474
Policy instance 7
Insurance contract or identification number3336474
Number of Individuals Covered995
Insurance policy start date2017-11-01
Insurance policy end date2018-10-31
Total amount of commissions paid to insurance brokerUSD $90,114
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,346,234
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
BLUE CROSS BLUE SHIELD OF ALABAMA (National Association of Insurance Commissioners NAIC id number: 55433 )
Policy contract number75070
Policy instance 8
Insurance contract or identification number75070
Number of Individuals Covered215
Insurance policy start date2017-11-01
Insurance policy end date2018-10-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberLK 751266
Policy instance 1
Insurance contract or identification numberLK 751266
Number of Individuals Covered317
Insurance policy start date2017-11-01
Insurance policy end date2018-10-31
Total amount of commissions paid to insurance brokerUSD $1,385
Total amount of fees paid to insurance companyUSD $266
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $13,849
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No

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