AFFILIATED SANTE GROUP has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan AFFILIATED SANTE GROUP, INC. FLEXIBLE BENEFITS PLAN
401k plan membership statisitcs for AFFILIATED SANTE GROUP, INC. FLEXIBLE BENEFITS PLAN
| Measure | Date | Value |
|---|
| 2023: AFFILIATED SANTE GROUP, INC. FLEXIBLE BENEFITS PLAN 2023 401k membership |
|---|
| Total participants, beginning-of-year | 2023-01-01 | 392 |
| Total number of active participants reported on line 7a of the Form 5500 | 2023-01-01 | 385 |
| Number of retired or separated participants receiving benefits | 2023-01-01 | 0 |
| Total of all active and inactive participants | 2023-01-01 | 385 |
| Total participants | 2023-01-01 | 385 |
| 2022: AFFILIATED SANTE GROUP, INC. FLEXIBLE BENEFITS PLAN 2022 401k membership |
|---|
| Total participants, beginning-of-year | 2022-01-01 | 345 |
| Total number of active participants reported on line 7a of the Form 5500 | 2022-01-01 | 390 |
| Number of retired or separated participants receiving benefits | 2022-01-01 | 2 |
| Total of all active and inactive participants | 2022-01-01 | 392 |
| Total participants | 2022-01-01 | 392 |
| 2021: AFFILIATED SANTE GROUP, INC. FLEXIBLE BENEFITS PLAN 2021 401k membership |
|---|
| Total participants, beginning-of-year | 2021-01-01 | 289 |
| Total number of active participants reported on line 7a of the Form 5500 | 2021-01-01 | 344 |
| Number of retired or separated participants receiving benefits | 2021-01-01 | 1 |
| Number of other retired or separated participants entitled to future benefits | 2021-01-01 | 0 |
| Total of all active and inactive participants | 2021-01-01 | 345 |
| 2020: AFFILIATED SANTE GROUP, INC. FLEXIBLE BENEFITS PLAN 2020 401k membership |
|---|
| Total participants, beginning-of-year | 2020-01-01 | 269 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-01-01 | 286 |
| Number of retired or separated participants receiving benefits | 2020-01-01 | 3 |
| Number of other retired or separated participants entitled to future benefits | 2020-01-01 | 0 |
| Total of all active and inactive participants | 2020-01-01 | 289 |
| 2019: AFFILIATED SANTE GROUP, INC. FLEXIBLE BENEFITS PLAN 2019 401k membership |
|---|
| Total participants, beginning-of-year | 2019-01-01 | 269 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-01-01 | 269 |
| Number of retired or separated participants receiving benefits | 2019-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2019-01-01 | 0 |
| Total of all active and inactive participants | 2019-01-01 | 269 |
| 2018: AFFILIATED SANTE GROUP, INC. FLEXIBLE BENEFITS PLAN 2018 401k membership |
|---|
| Total participants, beginning-of-year | 2018-01-01 | 210 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-01-01 | 268 |
| Number of retired or separated participants receiving benefits | 2018-01-01 | 1 |
| Number of other retired or separated participants entitled to future benefits | 2018-01-01 | 0 |
| Total of all active and inactive participants | 2018-01-01 | 269 |
| 2017: AFFILIATED SANTE GROUP, INC. FLEXIBLE BENEFITS PLAN 2017 401k membership |
|---|
| Total participants, beginning-of-year | 2017-02-01 | 100 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-02-01 | 207 |
| Number of retired or separated participants receiving benefits | 2017-02-01 | 3 |
| Number of other retired or separated participants entitled to future benefits | 2017-02-01 | 0 |
| Total of all active and inactive participants | 2017-02-01 | 210 |
| 2016: AFFILIATED SANTE GROUP, INC. FLEXIBLE BENEFITS PLAN 2016 401k membership |
|---|
| Total participants, beginning-of-year | 2016-02-01 | 161 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-02-01 | 0 |
| Number of retired or separated participants receiving benefits | 2016-02-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2016-02-01 | 0 |
| Total of all active and inactive participants | 2016-02-01 | 0 |
| 2015: AFFILIATED SANTE GROUP, INC. FLEXIBLE BENEFITS PLAN 2015 401k membership |
|---|
| Total participants, beginning-of-year | 2015-02-01 | 169 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-02-01 | 279 |
| Number of retired or separated participants receiving benefits | 2015-02-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2015-02-01 | 0 |
| Total of all active and inactive participants | 2015-02-01 | 279 |
| 2014: AFFILIATED SANTE GROUP, INC. FLEXIBLE BENEFITS PLAN 2014 401k membership |
|---|
| Total participants, beginning-of-year | 2014-02-01 | 191 |
| Total number of active participants reported on line 7a of the Form 5500 | 2014-02-01 | 169 |
| Number of retired or separated participants receiving benefits | 2014-02-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2014-02-01 | 0 |
| Total of all active and inactive participants | 2014-02-01 | 169 |
| 2013: AFFILIATED SANTE GROUP, INC. FLEXIBLE BENEFITS PLAN 2013 401k membership |
|---|
| Total participants, beginning-of-year | 2013-02-01 | 189 |
| Total number of active participants reported on line 7a of the Form 5500 | 2013-02-01 | 190 |
| Number of retired or separated participants receiving benefits | 2013-02-01 | 1 |
| Total of all active and inactive participants | 2013-02-01 | 191 |
| Total participants | 2013-02-01 | 191 |
| 2012: AFFILIATED SANTE GROUP, INC. FLEXIBLE BENEFITS PLAN 2012 401k membership |
|---|
| Total participants, beginning-of-year | 2012-02-01 | 193 |
| Total number of active participants reported on line 7a of the Form 5500 | 2012-02-01 | 188 |
| Number of retired or separated participants receiving benefits | 2012-02-01 | 1 |
| Total of all active and inactive participants | 2012-02-01 | 189 |
| Total participants | 2012-02-01 | 189 |
| 2011: AFFILIATED SANTE GROUP, INC. FLEXIBLE BENEFITS PLAN 2011 401k membership |
|---|
| Total participants, beginning-of-year | 2011-02-01 | 130 |
| Total number of active participants reported on line 7a of the Form 5500 | 2011-02-01 | 191 |
| Number of retired or separated participants receiving benefits | 2011-02-01 | 2 |
| Number of other retired or separated participants entitled to future benefits | 2011-02-01 | 0 |
| Total of all active and inactive participants | 2011-02-01 | 193 |
| Total participants | 2011-02-01 | 193 |
| 2009: AFFILIATED SANTE GROUP, INC. FLEXIBLE BENEFITS PLAN 2009 401k membership |
|---|
| Total participants, beginning-of-year | 2009-02-01 | 163 |
| Total number of active participants reported on line 7a of the Form 5500 | 2009-02-01 | 156 |
| Number of retired or separated participants receiving benefits | 2009-02-01 | 1 |
| Number of other retired or separated participants entitled to future benefits | 2009-02-01 | 0 |
| Total of all active and inactive participants | 2009-02-01 | 157 |
| Total participants | 2009-02-01 | 0 |
| 2023: AFFILIATED SANTE GROUP, INC. FLEXIBLE BENEFITS PLAN 2023 form 5500 responses |
|---|
| 2023-01-01 | Type of plan entity | Single employer plan |
| 2023-01-01 | Submission has been amended | No |
| 2023-01-01 | This submission is the final filing | No |
| 2023-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2023-01-01 | Plan is a collectively bargained plan | No |
| 2023-01-01 | Plan funding arrangement – Insurance | Yes |
| 2023-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2022: AFFILIATED SANTE GROUP, INC. FLEXIBLE BENEFITS PLAN 2022 form 5500 responses |
|---|
| 2022-01-01 | Type of plan entity | Single employer plan |
| 2022-01-01 | Submission has been amended | No |
| 2022-01-01 | This submission is the final filing | No |
| 2022-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2022-01-01 | Plan is a collectively bargained plan | No |
| 2022-01-01 | Plan funding arrangement – Insurance | Yes |
| 2022-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2021: AFFILIATED SANTE GROUP, INC. FLEXIBLE BENEFITS PLAN 2021 form 5500 responses |
|---|
| 2021-01-01 | Type of plan entity | Single employer plan |
| 2021-01-01 | Submission has been amended | No |
| 2021-01-01 | This submission is the final filing | No |
| 2021-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2021-01-01 | Plan is a collectively bargained plan | No |
| 2021-01-01 | Plan funding arrangement – Insurance | Yes |
| 2021-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2020: AFFILIATED SANTE GROUP, INC. FLEXIBLE BENEFITS PLAN 2020 form 5500 responses |
|---|
| 2020-01-01 | Type of plan entity | Single employer plan |
| 2020-01-01 | Submission has been amended | No |
| 2020-01-01 | This submission is the final filing | No |
| 2020-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2020-01-01 | Plan is a collectively bargained plan | No |
| 2020-01-01 | Plan funding arrangement – Insurance | Yes |
| 2020-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2019: AFFILIATED SANTE GROUP, INC. FLEXIBLE BENEFITS PLAN 2019 form 5500 responses |
|---|
| 2019-01-01 | Type of plan entity | Single employer plan |
| 2019-01-01 | Submission has been amended | No |
| 2019-01-01 | This submission is the final filing | No |
| 2019-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2019-01-01 | Plan is a collectively bargained plan | No |
| 2019-01-01 | Plan funding arrangement – Insurance | Yes |
| 2019-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2018: AFFILIATED SANTE GROUP, INC. FLEXIBLE BENEFITS PLAN 2018 form 5500 responses |
|---|
| 2018-01-01 | Type of plan entity | Single employer plan |
| 2018-01-01 | Submission has been amended | No |
| 2018-01-01 | This submission is the final filing | No |
| 2018-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2018-01-01 | Plan is a collectively bargained plan | No |
| 2018-01-01 | Plan funding arrangement – Insurance | Yes |
| 2018-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2017: AFFILIATED SANTE GROUP, INC. FLEXIBLE BENEFITS PLAN 2017 form 5500 responses |
|---|
| 2017-02-01 | Type of plan entity | Single employer plan |
| 2017-02-01 | Submission has been amended | No |
| 2017-02-01 | This submission is the final filing | No |
| 2017-02-01 | This return/report is a short plan year return/report (less than 12 months) | Yes |
| 2017-02-01 | Plan is a collectively bargained plan | No |
| 2017-02-01 | Plan funding arrangement – Insurance | Yes |
| 2017-02-01 | Plan benefit arrangement – Insurance | Yes |
| 2016: AFFILIATED SANTE GROUP, INC. FLEXIBLE BENEFITS PLAN 2016 form 5500 responses |
|---|
| 2016-02-01 | Type of plan entity | Single employer plan |
| 2016-02-01 | This submission is the final filing | Yes |
| 2016-02-01 | Plan funding arrangement – Insurance | Yes |
| 2016-02-01 | Plan benefit arrangement – Insurance | Yes |
| 2015: AFFILIATED SANTE GROUP, INC. FLEXIBLE BENEFITS PLAN 2015 form 5500 responses |
|---|
| 2015-02-01 | Type of plan entity | Single employer plan |
| 2015-02-01 | Submission has been amended | No |
| 2015-02-01 | This submission is the final filing | No |
| 2015-02-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2015-02-01 | Plan is a collectively bargained plan | No |
| 2015-02-01 | Plan funding arrangement – Insurance | Yes |
| 2015-02-01 | Plan benefit arrangement – Insurance | Yes |
| 2014: AFFILIATED SANTE GROUP, INC. FLEXIBLE BENEFITS PLAN 2014 form 5500 responses |
|---|
| 2014-02-01 | Type of plan entity | Single employer plan |
| 2014-02-01 | Submission has been amended | No |
| 2014-02-01 | This submission is the final filing | No |
| 2014-02-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2014-02-01 | Plan is a collectively bargained plan | No |
| 2014-02-01 | Plan funding arrangement – Insurance | Yes |
| 2014-02-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2014-02-01 | Plan benefit arrangement – Insurance | Yes |
| 2014-02-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2013: AFFILIATED SANTE GROUP, INC. FLEXIBLE BENEFITS PLAN 2013 form 5500 responses |
|---|
| 2013-02-01 | Type of plan entity | Single employer plan |
| 2013-02-01 | Submission has been amended | No |
| 2013-02-01 | This submission is the final filing | No |
| 2013-02-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2013-02-01 | Plan is a collectively bargained plan | No |
| 2013-02-01 | Plan funding arrangement – Insurance | Yes |
| 2013-02-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2013-02-01 | Plan benefit arrangement – Insurance | Yes |
| 2013-02-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2012: AFFILIATED SANTE GROUP, INC. FLEXIBLE BENEFITS PLAN 2012 form 5500 responses |
|---|
| 2012-02-01 | Type of plan entity | Single employer plan |
| 2012-02-01 | Submission has been amended | No |
| 2012-02-01 | This submission is the final filing | No |
| 2012-02-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2012-02-01 | Plan is a collectively bargained plan | No |
| 2012-02-01 | Plan funding arrangement – Insurance | Yes |
| 2012-02-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2012-02-01 | Plan benefit arrangement – Insurance | Yes |
| 2012-02-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2011: AFFILIATED SANTE GROUP, INC. FLEXIBLE BENEFITS PLAN 2011 form 5500 responses |
|---|
| 2011-02-01 | Type of plan entity | Single employer plan |
| 2011-02-01 | Submission has been amended | No |
| 2011-02-01 | This submission is the final filing | No |
| 2011-02-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2011-02-01 | Plan is a collectively bargained plan | No |
| 2011-02-01 | Plan funding arrangement – Insurance | Yes |
| 2011-02-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2011-02-01 | Plan benefit arrangement – Insurance | Yes |
| 2011-02-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2009: AFFILIATED SANTE GROUP, INC. FLEXIBLE BENEFITS PLAN 2009 form 5500 responses |
|---|
| 2009-02-01 | Type of plan entity | Single employer plan |
| 2009-02-01 | Submission has been amended | No |
| 2009-02-01 | This submission is the final filing | No |
| 2009-02-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2009-02-01 | Plan is a collectively bargained plan | No |
| 2009-02-01 | Plan funding arrangement – Insurance | Yes |
| 2009-02-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2009-02-01 | Plan benefit arrangement – Insurance | Yes |
| 2009-02-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 97423131001 |
| Policy instance | 3 |
| Insurance contract or identification number | 97423131001 | | Number of Individuals Covered | 206 | | Insurance policy start date | 2023-01-01 | | Insurance policy end date | 2023-12-31 | | Total amount of commissions paid to insurance broker | USD $1,020 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $12,986 |
|
| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
| Policy contract number | 3344781 |
| Policy instance | 2 |
| Insurance contract or identification number | 3344781 | | Number of Individuals Covered | 159 | | Insurance policy start date | 2023-01-01 | | Insurance policy end date | 2023-12-31 | | Total amount of commissions paid to insurance broker | USD $3,779 | | Total amount of fees paid to insurance company | USD $63,355 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $1,912,026 |
|
| AMERICAN UNITED LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60895 ) |
| Policy contract number | G 00613352 |
| Policy instance | 1 |
| Insurance contract or identification number | G 00613352 | | Number of Individuals Covered | 272 | | Insurance policy start date | 2023-01-01 | | Insurance policy end date | 2023-12-31 | | Total amount of commissions paid to insurance broker | USD $15,025 | | Total amount of fees paid to insurance company | USD $6,069 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | AD&D, VOLUNTARY LIFE AND AD&D, DEPENDENT LIFE | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $121,375 |
|
| COUNTRY WIDE PREPAID LEGAL SERVICES INC. (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | NA |
| Policy instance | 2 |
| Insurance contract or identification number | NA | | Number of Individuals Covered | 22 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | PREPAID LEGAL | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $2,664 |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 97423131001 |
| Policy instance | 3 |
| Insurance contract or identification number | 97423131001 | | Number of Individuals Covered | 214 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $1,350 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $15,562 | | Commission paid to Insurance Broker | USD $1,350 | | Insurance broker organization code? | 3 |
|
| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
| Policy contract number | 3344781 |
| Policy instance | 4 |
| Insurance contract or identification number | 3344781 | | Number of Individuals Covered | 154 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $3,771 | | Total amount of fees paid to insurance company | USD $67,778 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $1,850,387 | | Commission paid to Insurance Broker | USD $3,771 | | Amount paid for insurance broker fees | 67778 | | Additional information about fees paid to insurance broker | BENEFIT ADVISOR FEES AND INCENTIVE | | Insurance broker organization code? | 3 |
|
| AMERICAN UNITED LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60895 ) |
| Policy contract number | G 00613352 |
| Policy instance | 1 |
| Insurance contract or identification number | G 00613352 | | Number of Individuals Covered | 298 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $14,599 | | Total amount of fees paid to insurance company | USD $6,022 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | AD&D, VOLUNTARY LIFE AND AD&D, DEPENDENT LIFE | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $120,448 | | Commission paid to Insurance Broker | USD $14,599 | | Amount paid for insurance broker fees | 6022 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 0916082 |
| Policy instance | 4 |
| Insurance contract or identification number | 0916082 | | Number of Individuals Covered | 163 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $60,789 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $1,435,487 | | Commission paid to Insurance Broker | USD $60,789 | | Insurance broker organization code? | 3 |
|
| COUNTRY WIDE PREPAID LEGAL SERVICES INC. (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | NA |
| Policy instance | 2 |
| Insurance contract or identification number | NA | | Number of Individuals Covered | 20 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $665 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | PREPAID LEGAL | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $3,348 | | Commission paid to Insurance Broker | USD $665 | | Insurance broker organization code? | 3 |
|
| AMERICAN UNITED LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60895 ) |
| Policy contract number | G 00613352 |
| Policy instance | 1 |
| Insurance contract or identification number | G 00613352 | | Number of Individuals Covered | 344 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $13,282 | | Total amount of fees paid to insurance company | USD $5,395 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | AD&D, VOLUNTARY LIFE & AD&D, DEPENDENT LIFE | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $107,909 | | Commission paid to Insurance Broker | USD $13,282 | | Amount paid for insurance broker fees | 5395 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 97423131001 |
| Policy instance | 3 |
| Insurance contract or identification number | 97423131001 | | Number of Individuals Covered | 125 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $964 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $13,774 | | Commission paid to Insurance Broker | USD $964 | | Insurance broker organization code? | 3 |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 235630 |
| Policy instance | 3 |
| Insurance contract or identification number | 235630 | | Number of Individuals Covered | 144 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $9,074 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $101,366 | | Commission paid to Insurance Broker | USD $9,074 | | Insurance broker organization code? | 3 |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 0916082 |
| Policy instance | 4 |
| Insurance contract or identification number | 0916082 | | Number of Individuals Covered | 162 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $39,131 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $1,220,750 | | Commission paid to Insurance Broker | USD $39,131 | | Insurance broker organization code? | 3 |
|
| AMERICAN UNITED LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60895 ) |
| Policy contract number | G 00613352 |
| Policy instance | 1 |
| Insurance contract or identification number | G 00613352 | | Number of Individuals Covered | 286 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $12,547 | | Total amount of fees paid to insurance company | USD $5,073 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | AD&D, VOLUNTARY LIFE & AD&D PRODUCTS | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $101,480 | | Commission paid to Insurance Broker | USD $12,547 | | Amount paid for insurance broker fees | 5067 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 97423131001 |
| Policy instance | 2 |
| Insurance contract or identification number | 97423131001 | | Number of Individuals Covered | 117 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $880 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $12,576 | | Commission paid to Insurance Broker | USD $880 | | Insurance broker organization code? | 3 |
|
| AMERICAN UNITED LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60895 ) |
| Policy contract number | G 00613352 |
| Policy instance | 1 |
| Insurance contract or identification number | G 00613352 | | Number of Individuals Covered | 269 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $15,312 | | Total amount of fees paid to insurance company | USD $9,595 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | AD&D, VOLUNTARY LIFE & AD&D PRODUCTS | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $127,358 | | Commission paid to Insurance Broker | USD $15,312 | | Amount paid for insurance broker fees | 9576 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 0916082 |
| Policy instance | 4 |
| Insurance contract or identification number | 0916082 | | Number of Individuals Covered | 155 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $48,897 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $1,086,605 | | Commission paid to Insurance Broker | USD $48,897 | | Insurance broker organization code? | 3 |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 235630 |
| Policy instance | 3 |
| Insurance contract or identification number | 235630 | | Number of Individuals Covered | 160 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $4,816 | | Total amount of fees paid to insurance company | USD $3,378 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $103,593 | | Commission paid to Insurance Broker | USD $4,816 | | Amount paid for insurance broker fees | 3378 | | Additional information about fees paid to insurance broker | SPECIAL PRODUCER | | Insurance broker organization code? | 3 |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 97423131001 |
| Policy instance | 2 |
| Insurance contract or identification number | 97423131001 | | Number of Individuals Covered | 121 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $923 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $13,190 | | Commission paid to Insurance Broker | USD $923 | | Insurance broker organization code? | 3 |
|
| CAREFIRST BLUECHOICE (National Association of Insurance Commissioners NAIC id number: 96202 ) |
| Policy contract number | 1VJQ |
| Policy instance | 2 |
| Insurance contract or identification number | 1VJQ | | Number of Individuals Covered | 149 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $47,430 | | Total amount of fees paid to insurance company | USD $30,073 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $948,569 | | Commission paid to Insurance Broker | USD $47,430 | | Amount paid for insurance broker fees | 30073 | | Additional information about fees paid to insurance broker | WHOLESALER FEE NON-MONETARY INCENTIVE AMOUNT MEDICAL CONTRACTS X PCPM | | Insurance broker organization code? | 3 |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 235630 |
| Policy instance | 4 |
| Insurance contract or identification number | 235630 | | Number of Individuals Covered | 164 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $4,391 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $92,081 | | Commission paid to Insurance Broker | USD $4,387 | | Insurance broker organization code? | 3 |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 97423131001 |
| Policy instance | 3 |
| Insurance contract or identification number | 97423131001 | | Number of Individuals Covered | 166 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $912 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $11,563 | | Commission paid to Insurance Broker | USD $746 | | Insurance broker organization code? | 3 |
|
| AMERICAN UNITED LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60895 ) |
| Policy contract number | G 00613352 |
| Policy instance | 1 |
| Insurance contract or identification number | G 00613352 | | Number of Individuals Covered | 268 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $3,437 | | Total amount of fees paid to insurance company | USD $3,712 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | AD&D, VOLUNTARY LIFE & AD&D PRODUCTS | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $93,705 | | Commission paid to Insurance Broker | USD $3,437 | | Amount paid for insurance broker fees | 2357 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| AMERICAN UNITED LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60895 ) |
| Policy contract number | G 00613352 |
| Policy instance | 1 |
| Insurance contract or identification number | G 00613352 | | Number of Individuals Covered | 207 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $9,795 | | Total amount of fees paid to insurance company | USD $3,895 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | AD&D, VOLUNTARY LIFE & AD&D PRODUCTS | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $77,909 | | Commission paid to Insurance Broker | USD $9,795 | | Amount paid for insurance broker fees | 104 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | RICHARD J PRINCINSKY & ASSOC |
|
| CAREFIRST BLUECHOICE (National Association of Insurance Commissioners NAIC id number: 96202 ) |
| Policy contract number | 1VJQ |
| Policy instance | 2 |
| Insurance contract or identification number | 1VJQ | | Number of Individuals Covered | 130 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $29,514 | | Total amount of fees paid to insurance company | USD $17,220 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $590,297 | | Commission paid to Insurance Broker | USD $20,195 | | Amount paid for insurance broker fees | 11915 | | Additional information about fees paid to insurance broker | NON-MONETARY INCENTIVE AMOUNT MEDICAL CONTRACTS X PCPM | | Insurance broker organization code? | 3 | | Insurance broker name | BENEFIT DESIGN GROUP INC |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 97423131001 |
| Policy instance | 3 |
| Insurance contract or identification number | 97423131001 | | Number of Individuals Covered | 148 | | Insurance policy start date | 2017-02-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $853 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $9,641 | | Commission paid to Insurance Broker | USD $853 | | Insurance broker organization code? | 3 | | Insurance broker name | USI INSURANCE SERVICES LLC |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 235630 |
| Policy instance | 4 |
| Insurance contract or identification number | 235630 | | Number of Individuals Covered | 130 | | Insurance policy start date | 2017-02-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $2,553 | | Total amount of fees paid to insurance company | USD $4,275 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $75,507 | | Commission paid to Insurance Broker | USD $2,025 | | Amount paid for insurance broker fees | 4275 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker organization code? | 3 | | Insurance broker name | KELLY & ASSOCIATES INSURANCE GROUP |
|
| GHMSI (National Association of Insurance Commissioners NAIC id number: 53007 ) |
| Policy contract number | IVJQ |
| Policy instance | 4 |
| Insurance contract or identification number | IVJQ | | Number of Individuals Covered | 142 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $27,294 | | Total amount of fees paid to insurance company | USD $16,342 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $545,887 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $27,294 | | Amount paid for insurance broker fees | 16342 | | Additional information about fees paid to insurance broker | NEW BUSINESS BONUS MEDICAL CONTRACTS X PCPM NON-MONETARY INCENTIVE | | Insurance broker organization code? | 3 | | Insurance broker name | RICHARD J. PRINCINSKY AND ASSOC INC |
|
| AMERICAN UNITED LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60895 ) |
| Policy contract number | G00613352 |
| Policy instance | 3 |
| Insurance contract or identification number | G00613352 | | Number of Individuals Covered | 173 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $10,203 | | Total amount of fees paid to insurance company | USD $4,552 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT EMPLOYEE ASSISTANCE PROGRAM | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $67,508 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $8,606 | | Amount paid for insurance broker fees | 360 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | RICHARD J. PRINCINSKY AND ASSOC INC |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 9742313 |
| Policy instance | 2 |
| Insurance contract or identification number | 9742313 | | Number of Individuals Covered | 121 | | Insurance policy start date | 2015-02-01 | | Insurance policy end date | 2016-01-31 | | Total amount of commissions paid to insurance broker | USD $837 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $7,855 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $837 | | Insurance broker organization code? | 3 | | Insurance broker name | USI INSURANCE SERVICES, LLC |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 235630 |
| Policy instance | 1 |
| Insurance contract or identification number | 235630 | | Number of Individuals Covered | 122 | | Insurance policy start date | 2015-02-01 | | Insurance policy end date | 2016-01-31 | | Total amount of commissions paid to insurance broker | USD $2,477 | | Total amount of fees paid to insurance company | USD $4,547 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $76,514 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,643 | | Amount paid for insurance broker fees | 4547 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker organization code? | 3 | | Insurance broker name | USI INSURANCE SERVICES, LLC |
|
| AMERICAN UNITED LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60895 ) |
| Policy contract number | G00613352 |
| Policy instance | 4 |
| Insurance contract or identification number | G00613352 | | Number of Individuals Covered | 169 | | Insurance policy start date | 2014-04-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $6,360 | | Total amount of fees paid to insurance company | USD $7 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT EMPLOYEE ASSISTANCE PROGRAM | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $49,906 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $6,360 | | Amount paid for insurance broker fees | 7 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | USI INSURANCE SERVICES, LLC |
|
| PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 ) |
| Policy contract number | 9646 |
| Policy instance | 3 |
| Insurance contract or identification number | 9646 | | Number of Individuals Covered | 92 | | Insurance policy start date | 2014-02-01 | | Insurance policy end date | 2014-03-31 | | Total amount of commissions paid to insurance broker | USD $1,084 | | Total amount of fees paid to insurance company | USD $253 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND 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 Carrier | USD $10,844 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,084 | | Amount paid for insurance broker fees | 245 | | Additional information about fees paid to insurance broker | SUPPLEMENTAL COMMISSIONS | | Insurance broker organization code? | 3 | | Insurance broker name | AXA ASSISTANCE, USA |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 9742313 |
| Policy instance | 2 |
| Insurance contract or identification number | 9742313 | | Number of Individuals Covered | 99 | | Insurance policy start date | 2014-02-01 | | Insurance policy end date | 2015-01-31 | | Total amount of commissions paid to insurance broker | USD $691 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $6,996 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $691 | | Insurance broker organization code? | 3 | | Insurance broker name | USI INSURANCE SERVICES, LLC |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 235630 |
| Policy instance | 1 |
| Insurance contract or identification number | 235630 | | Number of Individuals Covered | 111 | | Insurance policy start date | 2014-02-01 | | Insurance policy end date | 2015-01-31 | | Total amount of commissions paid to insurance broker | USD $2,036 | | Total amount of fees paid to insurance company | USD $2,457 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $69,541 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,036 | | Amount paid for insurance broker fees | 2457 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker organization code? | 3 | | Insurance broker name | USI INSURANCE SERVICES, LLC |
|
| CAREFIRST BLUECHOICE (National Association of Insurance Commissioners NAIC id number: 96202 ) |
| Policy contract number | 7L63 |
| Policy instance | 1 |
| Insurance contract or identification number | 7L63 | | Number of Individuals Covered | 98 | | Insurance policy start date | 2013-02-01 | | Insurance policy end date | 2014-01-31 | | Total amount of commissions paid to insurance broker | USD $19,956 | | Total amount of fees paid to insurance company | USD $8,228 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $570,175 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $19,956 | | Amount paid for insurance broker fees | 8228 | | Additional information about fees paid to insurance broker | MEDICAL CONTRACTS X PCPM; NON-MONETARY INCENTIVE AMOUNT | | Insurance broker organization code? | 3 | | Insurance broker name | RICHARD J PRINCINSKY & ASSOC., INC. |
|
| BLUECROSS BLUESHIELD OF NORTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 54631 ) |
| Policy contract number | 070911 |
| Policy instance | 5 |
| Insurance contract or identification number | 070911 | | Number of Individuals Covered | 6 | | Insurance policy start date | 2013-02-01 | | Insurance policy end date | 2014-01-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $40,851 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 00235630 |
| Policy instance | 3 |
| Insurance contract or identification number | 00235630 | | Number of Individuals Covered | 119 | | Insurance policy start date | 2013-02-01 | | Insurance policy end date | 2014-01-31 | | Total amount of commissions paid to insurance broker | USD $2,033 | | Total amount of fees paid to insurance company | USD $3,432 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $69,373 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,033 | | Amount paid for insurance broker fees | 3432 | | Additional information about fees paid to insurance broker | SPECIAL PRODUCER COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | USI INSURANCE SERVICES LLC |
|
| PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 ) |
| Policy contract number | 09646 |
| Policy instance | 4 |
| Insurance contract or identification number | 09646 | | Number of Individuals Covered | 190 | | Insurance policy start date | 2013-02-01 | | Insurance policy end date | 2014-01-31 | | Total amount of commissions paid to insurance broker | USD $7,960 | | Total amount of fees paid to insurance company | USD $68 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL 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 Carrier | USD $159,191 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,960 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Additional information about fees paid to insurance broker | THIRD PARTY ADMINISTRATION FEES | | Insurance broker name | AXA ASSISTANCE, USA |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 9742313 |
| Policy instance | 2 |
| Insurance contract or identification number | 9742313 | | Number of Individuals Covered | 95 | | Insurance policy start date | 2013-02-01 | | Insurance policy end date | 2014-01-31 | | Total amount of commissions paid to insurance broker | USD $839 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $8,389 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $839 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | RICHARD J PRINCINSKY & ASSOC., INC. |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 9742313 |
| Policy instance | 2 |
| Insurance contract or identification number | 9742313 | | Number of Individuals Covered | 96 | | Insurance policy start date | 2012-02-01 | | Insurance policy end date | 2013-01-31 | | Total amount of commissions paid to insurance broker | USD $1,109 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $11,089 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,109 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | RICHARD J PRINCINSKY & ASSOC |
|
| BLUECROSS BLUESHIELD OF NORTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 54631 ) |
| Policy contract number | 070911 |
| Policy instance | 5 |
| Insurance contract or identification number | 070911 | | Number of Individuals Covered | 4 | | Insurance policy start date | 2012-02-01 | | Insurance policy end date | 2013-01-31 | | Total amount of commissions paid to insurance broker | USD $1,708 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $47,250 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,708 | | Amount paid for insurance broker fees | 0 | | Insurance broker name | GRADY, DANIELLE D |
|
| PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 ) |
| Policy contract number | 09646 |
| Policy instance | 4 |
| Insurance contract or identification number | 09646 | | Number of Individuals Covered | 188 | | Insurance policy start date | 2012-02-01 | | Insurance policy end date | 2013-01-31 | | Total amount of commissions paid to insurance broker | USD $8,921 | | Total amount of fees paid to insurance company | USD $72 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $152,616 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,921 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Additional information about fees paid to insurance broker | THIRD PARTY ADMINISTRATION | | Insurance broker name | AXA ASSISTANCE |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 00235630 |
| Policy instance | 3 |
| Insurance contract or identification number | 00235630 | | Number of Individuals Covered | 121 | | Insurance policy start date | 2012-02-01 | | Insurance policy end date | 2013-01-31 | | Total amount of commissions paid to insurance broker | USD $1,707 | | Total amount of fees paid to insurance company | USD $2,003 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $67,242 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,707 | | Amount paid for insurance broker fees | 2003 | | Insurance broker organization code? | 3 | | Insurance broker name | RICHARD J PRINCINSKY & ASSOC |
|
| CAREFIRST BLUECHOICE (National Association of Insurance Commissioners NAIC id number: 96202 ) |
| Policy contract number | 7L63 |
| Policy instance | 1 |
| Insurance contract or identification number | 7L63 | | Number of Individuals Covered | 108 | | Insurance policy start date | 2012-02-01 | | Insurance policy end date | 2013-01-31 | | Total amount of commissions paid to insurance broker | USD $17,360 | | Total amount of fees paid to insurance company | USD $8,497 | | Health Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $495,998 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $17,360 | | Amount paid for insurance broker fees | 8497 | | Additional information about fees paid to insurance broker | MEDICAL CONTRACTS X PCPM; NON-MONETARY INCENTIVE | | Insurance broker organization code? | 3 | | Insurance broker name | RICHARD J PRINCINSKY & ASSOC |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000198B;VARIES |
| Policy instance | 6 |
| Insurance contract or identification number | G000198B;VARIES | | Number of Individuals Covered | 51 | | Insurance policy start date | 2010-03-01 | | Insurance policy end date | 2011-02-28 | | Total amount of commissions paid to insurance broker | USD $5,350 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $41,116 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG 0198B |
| Policy instance | 7 |
| Insurance contract or identification number | GLUG 0198B | | Number of Individuals Covered | 131 | | Insurance policy start date | 2011-02-01 | | Insurance policy end date | 2011-02-28 | | Total amount of commissions paid to insurance broker | USD $78 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $781 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLTD0433J |
| Policy instance | 2 |
| Insurance contract or identification number | GLTD0433J | | Number of Individuals Covered | 18 | | Insurance policy start date | 2010-04-01 | | Insurance policy end date | 2011-03-31 | | Total amount of commissions paid to insurance broker | USD $1,637 | | Total amount of fees paid to insurance company | USD $0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $10,911 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 00235630 |
| Policy instance | 5 |
| Insurance contract or identification number | 00235630 | | Number of Individuals Covered | 123 | | Insurance policy start date | 2011-02-01 | | Insurance policy end date | 2012-01-31 | | Total amount of commissions paid to insurance broker | USD $2,051 | | Total amount of fees paid to insurance company | USD $2,905 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $70,083 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 9742313 |
| Policy instance | 4 |
| Insurance contract or identification number | 9742313 | | Number of Individuals Covered | 101 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2011-12-31 | | Total amount of commissions paid to insurance broker | USD $296 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $2,300 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 ) |
| Policy contract number | 09646 |
| Policy instance | 1 |
| Insurance contract or identification number | 09646 | | Number of Individuals Covered | 191 | | Insurance policy start date | 2011-03-01 | | Insurance policy end date | 2012-01-31 | | Total amount of commissions paid to insurance broker | USD $10,799 | | Total amount of fees paid to insurance company | USD $52 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $69,160 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| GHMSI (National Association of Insurance Commissioners NAIC id number: 53007 ) |
| Policy contract number | 7L63 |
| Policy instance | 3 |
| Insurance contract or identification number | 7L63 | | Number of Individuals Covered | 104 | | Insurance policy start date | 2011-02-01 | | Insurance policy end date | 2012-01-31 | | Total amount of commissions paid to insurance broker | USD $21,836 | | Total amount of fees paid to insurance company | USD $8,041 | | Health Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $623,899 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG 0198B |
| Policy instance | 5 |
| Insurance contract or identification number | GLUG 0198B | | Number of Individuals Covered | 129 | | Insurance policy start date | 2010-02-01 | | Insurance policy end date | 2011-01-31 | | Total amount of commissions paid to insurance broker | USD $999 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $9,989 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 00235630 |
| Policy instance | 1 |
| Insurance contract or identification number | 00235630 | | Number of Individuals Covered | 120 | | Insurance policy start date | 2010-02-01 | | Insurance policy end date | 2011-01-31 | | Total amount of commissions paid to insurance broker | USD $2,624 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $83,950 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 9742313 |
| Policy instance | 6 |
| Insurance contract or identification number | 9742313 | | Number of Individuals Covered | 115 | | Insurance policy start date | 2010-01-01 | | Insurance policy end date | 2010-12-31 | | Total amount of commissions paid to insurance broker | USD $920 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $8,683 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| GHMSI (National Association of Insurance Commissioners NAIC id number: 53007 ) |
| Policy contract number | 7L63 |
| Policy instance | 4 |
| Insurance contract or identification number | 7L63 | | Number of Individuals Covered | 107 | | Insurance policy start date | 2010-02-01 | | Insurance policy end date | 2011-01-31 | | Total amount of commissions paid to insurance broker | USD $27,293 | | Total amount of fees paid to insurance company | USD $8,966 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $682,325 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLTD0433J |
| Policy instance | 3 |
| Insurance contract or identification number | GLTD0433J | | Number of Individuals Covered | 17 | | Insurance policy start date | 2009-04-01 | | Insurance policy end date | 2010-03-31 | | Total amount of commissions paid to insurance broker | USD $1,677 | | Total amount of fees paid to insurance company | USD $0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $11,181 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000198B;VARIES |
| Policy instance | 2 |
| Insurance contract or identification number | G000198B;VARIES | | Number of Individuals Covered | 52 | | Insurance policy start date | 2009-03-01 | | Insurance policy end date | 2010-02-28 | | Total amount of commissions paid to insurance broker | USD $5,519 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $42,592 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
