CONVERGENZ, LLC has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan CONVERGENZ, LLC HEALTH & WELFARE PLAN
| Measure | Date | Value |
|---|
| 2022: CONVERGENZ, LLC HEALTH & WELFARE PLAN 2022 401k membership |
|---|
| Total participants, beginning-of-year | 2022-09-01 | 105 |
| Total number of active participants reported on line 7a of the Form 5500 | 2022-09-01 | 130 |
| Number of retired or separated participants receiving benefits | 2022-09-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2022-09-01 | 0 |
| Total of all active and inactive participants | 2022-09-01 | 130 |
| Number of employers contributing to the scheme | 2022-09-01 | 0 |
| 2018: CONVERGENZ, LLC HEALTH & WELFARE PLAN 2018 401k membership |
|---|
| Total participants, beginning-of-year | 2018-09-01 | 102 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-09-01 | 104 |
| Number of retired or separated participants receiving benefits | 2018-09-01 | 1 |
| Number of other retired or separated participants entitled to future benefits | 2018-09-01 | 0 |
| Total of all active and inactive participants | 2018-09-01 | 105 |
| Number of employers contributing to the scheme | 2018-09-01 | 0 |
| 2017: CONVERGENZ, LLC HEALTH & WELFARE PLAN 2017 401k membership |
|---|
| Total participants, beginning-of-year | 2017-09-01 | 100 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-09-01 | 100 |
| Number of retired or separated participants receiving benefits | 2017-09-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2017-09-01 | 0 |
| Total of all active and inactive participants | 2017-09-01 | 100 |
| Number of employers contributing to the scheme | 2017-09-01 | 0 |
| 2016: CONVERGENZ, LLC HEALTH & WELFARE PLAN 2016 401k membership |
|---|
| Total participants, beginning-of-year | 2016-09-01 | 112 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-09-01 | 100 |
| Number of retired or separated participants receiving benefits | 2016-09-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2016-09-01 | 0 |
| Total of all active and inactive participants | 2016-09-01 | 100 |
| 2015: CONVERGENZ, LLC HEALTH & WELFARE PLAN 2015 401k membership |
|---|
| Total participants, beginning-of-year | 2015-09-01 | 224 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-09-01 | 112 |
| Number of retired or separated participants receiving benefits | 2015-09-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2015-09-01 | 0 |
| Total of all active and inactive participants | 2015-09-01 | 112 |
| 2014: CONVERGENZ, LLC HEALTH & WELFARE PLAN 2014 401k membership |
|---|
| Total participants, beginning-of-year | 2014-09-01 | 120 |
| Total number of active participants reported on line 7a of the Form 5500 | 2014-09-01 | 214 |
| Number of retired or separated participants receiving benefits | 2014-09-01 | 10 |
| Number of other retired or separated participants entitled to future benefits | 2014-09-01 | 0 |
| Total of all active and inactive participants | 2014-09-01 | 224 |
| 2013: CONVERGENZ, LLC HEALTH & WELFARE PLAN 2013 401k membership |
|---|
| Total participants, beginning-of-year | 2013-09-01 | 300 |
| Total number of active participants reported on line 7a of the Form 5500 | 2013-09-01 | 161 |
| Number of retired or separated participants receiving benefits | 2013-09-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2013-09-01 | 0 |
| Total of all active and inactive participants | 2013-09-01 | 161 |
| 2012: CONVERGENZ, LLC HEALTH & WELFARE PLAN 2012 401k membership |
|---|
| Total participants, beginning-of-year | 2012-09-01 | 121 |
| Total number of active participants reported on line 7a of the Form 5500 | 2012-09-01 | 145 |
| Number of retired or separated participants receiving benefits | 2012-09-01 | 137 |
| Number of other retired or separated participants entitled to future benefits | 2012-09-01 | 18 |
| Total of all active and inactive participants | 2012-09-01 | 300 |
| 2011: CONVERGENZ, LLC HEALTH & WELFARE PLAN 2011 401k membership |
|---|
| Total participants, beginning-of-year | 2011-09-01 | 136 |
| Total number of active participants reported on line 7a of the Form 5500 | 2011-09-01 | 105 |
| Number of retired or separated participants receiving benefits | 2011-09-01 | 12 |
| Number of other retired or separated participants entitled to future benefits | 2011-09-01 | 0 |
| Total of all active and inactive participants | 2011-09-01 | 117 |
| 2010: CONVERGENZ, LLC HEALTH & WELFARE PLAN 2010 401k membership |
|---|
| Total participants, beginning-of-year | 2010-09-01 | 139 |
| Total number of active participants reported on line 7a of the Form 5500 | 2010-09-01 | 140 |
| Number of retired or separated participants receiving benefits | 2010-09-01 | 7 |
| Number of other retired or separated participants entitled to future benefits | 2010-09-01 | 0 |
| Total of all active and inactive participants | 2010-09-01 | 147 |
| 2009: CONVERGENZ, LLC HEALTH & WELFARE PLAN 2009 401k membership |
|---|
| Total participants, beginning-of-year | 2009-09-01 | 116 |
| Total number of active participants reported on line 7a of the Form 5500 | 2009-09-01 | 129 |
| Number of retired or separated participants receiving benefits | 2009-09-01 | 14 |
| Number of other retired or separated participants entitled to future benefits | 2009-09-01 | 0 |
| Total of all active and inactive participants | 2009-09-01 | 143 |
| 2022: CONVERGENZ, LLC HEALTH & WELFARE PLAN 2022 form 5500 responses |
|---|
| 2022-09-01 | Type of plan entity | Single employer plan |
| 2022-09-01 | Plan funding arrangement – Insurance | Yes |
| 2022-09-01 | Plan benefit arrangement – Insurance | Yes |
| 2018: CONVERGENZ, LLC HEALTH & WELFARE PLAN 2018 form 5500 responses |
|---|
| 2018-09-01 | Type of plan entity | Single employer plan |
| 2018-09-01 | Submission has been amended | Yes |
| 2018-09-01 | Plan funding arrangement – Insurance | Yes |
| 2018-09-01 | Plan benefit arrangement – Insurance | Yes |
| 2017: CONVERGENZ, LLC HEALTH & WELFARE PLAN 2017 form 5500 responses |
|---|
| 2017-09-01 | Type of plan entity | Single employer plan |
| 2017-09-01 | Plan funding arrangement – Insurance | Yes |
| 2017-09-01 | Plan benefit arrangement – Insurance | Yes |
| 2016: CONVERGENZ, LLC HEALTH & WELFARE PLAN 2016 form 5500 responses |
|---|
| 2016-09-01 | Type of plan entity | Single employer plan |
| 2016-09-01 | Submission has been amended | No |
| 2016-09-01 | This submission is the final filing | No |
| 2016-09-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2016-09-01 | Plan is a collectively bargained plan | No |
| 2016-09-01 | Plan funding arrangement – Insurance | Yes |
| 2016-09-01 | Plan benefit arrangement – Insurance | Yes |
| 2015: CONVERGENZ, LLC HEALTH & WELFARE PLAN 2015 form 5500 responses |
|---|
| 2015-09-01 | Type of plan entity | Single employer plan |
| 2015-09-01 | Submission has been amended | No |
| 2015-09-01 | This submission is the final filing | No |
| 2015-09-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2015-09-01 | Plan is a collectively bargained plan | No |
| 2015-09-01 | Plan funding arrangement – Insurance | Yes |
| 2015-09-01 | Plan benefit arrangement – Insurance | Yes |
| 2014: CONVERGENZ, LLC HEALTH & WELFARE PLAN 2014 form 5500 responses |
|---|
| 2014-09-01 | Type of plan entity | Single employer plan |
| 2014-09-01 | Submission has been amended | No |
| 2014-09-01 | This submission is the final filing | No |
| 2014-09-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2014-09-01 | Plan is a collectively bargained plan | No |
| 2014-09-01 | Plan funding arrangement – Insurance | Yes |
| 2014-09-01 | Plan benefit arrangement – Insurance | Yes |
| 2013: CONVERGENZ, LLC HEALTH & WELFARE PLAN 2013 form 5500 responses |
|---|
| 2013-09-01 | Type of plan entity | Single employer plan |
| 2013-09-01 | Submission has been amended | No |
| 2013-09-01 | This submission is the final filing | No |
| 2013-09-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2013-09-01 | Plan is a collectively bargained plan | No |
| 2013-09-01 | Plan funding arrangement – Insurance | Yes |
| 2013-09-01 | Plan benefit arrangement – Insurance | Yes |
| 2012: CONVERGENZ, LLC HEALTH & WELFARE PLAN 2012 form 5500 responses |
|---|
| 2012-09-01 | Type of plan entity | Single employer plan |
| 2012-09-01 | Submission has been amended | No |
| 2012-09-01 | This submission is the final filing | No |
| 2012-09-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2012-09-01 | Plan is a collectively bargained plan | No |
| 2012-09-01 | Plan funding arrangement – Insurance | Yes |
| 2012-09-01 | Plan benefit arrangement – Insurance | Yes |
| 2011: CONVERGENZ, LLC HEALTH & WELFARE PLAN 2011 form 5500 responses |
|---|
| 2011-09-01 | Type of plan entity | Single employer plan |
| 2011-09-01 | Submission has been amended | No |
| 2011-09-01 | This submission is the final filing | No |
| 2011-09-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2011-09-01 | Plan is a collectively bargained plan | No |
| 2011-09-01 | Plan funding arrangement – Insurance | Yes |
| 2011-09-01 | Plan benefit arrangement – Insurance | Yes |
| 2010: CONVERGENZ, LLC HEALTH & WELFARE PLAN 2010 form 5500 responses |
|---|
| 2010-09-01 | Type of plan entity | Single employer plan |
| 2010-09-01 | Submission has been amended | No |
| 2010-09-01 | This submission is the final filing | No |
| 2010-09-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2010-09-01 | Plan is a collectively bargained plan | No |
| 2010-09-01 | Plan funding arrangement – Insurance | Yes |
| 2010-09-01 | Plan benefit arrangement – Insurance | Yes |
| 2009: CONVERGENZ, LLC HEALTH & WELFARE PLAN 2009 form 5500 responses |
|---|
| 2009-09-01 | Type of plan entity | Single employer plan |
| 2009-09-01 | Submission has been amended | No |
| 2009-09-01 | This submission is the final filing | No |
| 2009-09-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2009-09-01 | Plan is a collectively bargained plan | No |
| 2009-09-01 | Plan funding arrangement – Insurance | Yes |
| 2009-09-01 | Plan benefit arrangement – Insurance | Yes |
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 541892 |
| Policy instance | 2 |
| Insurance contract or identification number | 541892 | | Number of Individuals Covered | 112 | | Insurance policy start date | 2022-09-01 | | Insurance policy end date | 2023-08-31 | | Total amount of commissions paid to insurance broker | USD $10,655 | | Total amount of fees paid to insurance company | USD $2,801 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT, EMPLOYEE ASSISTANCE PROGRAM | | Welfare Benefit Premiums Paid to Carrier | USD $99,603 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $10,655 | | Amount paid for insurance broker fees | 2801 | | Additional information about fees paid to insurance broker | FEES | | 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 | 3342085 |
| Policy instance | 1 |
| Insurance contract or identification number | 3342085 | | Number of Individuals Covered | 130 | | Insurance policy start date | 2022-09-01 | | Insurance policy end date | 2023-08-31 | | Total amount of commissions paid to insurance broker | USD $2,823 | | Total amount of fees paid to insurance company | USD $33,987 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,047,941 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,823 | | Amount paid for insurance broker fees | 33987 | | Additional information about fees paid to insurance broker | BENEFIT ADVISOR PAYMENTS | | 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 | 3342085 |
| Policy instance | 1 |
| Insurance contract or identification number | 3342085 | | Number of Individuals Covered | 104 | | Insurance policy start date | 2018-09-01 | | Insurance policy end date | 2019-08-31 | | Total amount of commissions paid to insurance broker | USD $1,912 | | Total amount of fees paid to insurance company | USD $38,591 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $722,544 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,912 | | Amount paid for insurance broker fees | 23468 | | Additional information about fees paid to insurance broker | BENEFIT ADVISOR PAYMENTS | | Insurance broker organization code? | 3 |
|
| GHMSI (National Association of Insurance Commissioners NAIC id number: 53007 ) |
| Policy contract number | XX39 |
| Policy instance | 1 |
| Insurance contract or identification number | XX39 | | Number of Individuals Covered | 144 | | Insurance policy start date | 2017-09-01 | | Insurance policy end date | 2018-08-31 | | Total amount of commissions paid to insurance broker | USD $31,484 | | Total amount of fees paid to insurance company | USD $10,449 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $899,505 | | 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 | XX39 |
| Policy instance | 1 |
| Insurance contract or identification number | XX39 | | Number of Individuals Covered | 198 | | Insurance policy start date | 2015-09-01 | | Insurance policy end date | 2016-08-31 | | Total amount of commissions paid to insurance broker | USD $30,578 | | Total amount of fees paid to insurance company | USD $8,863 | | 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 | Yes | | 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 $873,671 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $30,578 | | Amount paid for insurance broker fees | 8863 | | Additional information about fees paid to insurance broker | MEDICAL CONTRACTS X PCPM DENTAL CONTRACTS X PCPM NON-MONETARY INCENTIVE AMOUNT | | Insurance broker organization code? | 3 | | Insurance broker name | WELLS FARGO INSURANCE SERVICES |
|
| GHMSI (National Association of Insurance Commissioners NAIC id number: 53007 ) |
| Policy contract number | XX39 |
| Policy instance | 1 |
| Insurance contract or identification number | XX39 | | Number of Individuals Covered | 226 | | Insurance policy start date | 2014-09-01 | | Insurance policy end date | 2015-08-31 | | Total amount of commissions paid to insurance broker | USD $34,042 | | Total amount of fees paid to insurance company | USD $10,946 | | 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 | 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 $972,619 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $20,491 | | Amount paid for insurance broker fees | 10946 | | Additional information about fees paid to insurance broker | MEDICAL CONTRACTS X PCPM NON-MONETARY INCENTIVE AMOUNT | | Insurance broker organization code? | 3 | | Insurance broker name | WELLS FARGO INSURANCE SERVICES |
|
| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
| Policy contract number | TS05481410 |
| Policy instance | 2 |
| Insurance contract or identification number | TS05481410 | | Number of Individuals Covered | 214 | | Insurance policy start date | 2014-09-01 | | Insurance policy end date | 2015-08-31 | | Total amount of commissions paid to insurance broker | USD $10,788 | | Total amount of fees paid to insurance company | USD $692 | | 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 $76,387 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,281 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 692 | | Additional information about fees paid to insurance broker | SUPPLEMENTAL COMPENSATION | | Insurance broker name | NFP INSURANCE SERVICES, INC. |
|
| GHMSI (National Association of Insurance Commissioners NAIC id number: 53007 ) |
| Policy contract number | XX39 |
| Policy instance | 1 |
| Insurance contract or identification number | XX39 | | Number of Individuals Covered | 257 | | Insurance policy start date | 2013-09-01 | | Insurance policy end date | 2014-08-31 | | Total amount of commissions paid to insurance broker | USD $33,076 | | Total amount of fees paid to insurance company | USD $13,954 | | 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 | 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 $945,035 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $33,076 | | Amount paid for insurance broker fees | 13954 | | Additional information about fees paid to insurance broker | MEDICAL CONTRACTS X PCPM NON-MONETARY COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | THE MELTZER GROUP |
|
| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
| Policy contract number | TS05481410 |
| Policy instance | 2 |
| Insurance contract or identification number | TS05481410 | | Number of Individuals Covered | 172 | | Insurance policy start date | 2013-09-01 | | Insurance policy end date | 2014-08-31 | | Total amount of commissions paid to insurance broker | USD $8,931 | | 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 | 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 $60,902 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,090 | | Insurance broker organization code? | 3 | | Insurance broker name | NFP CORPORATE SERVICES |
|
| GHMSI (National Association of Insurance Commissioners NAIC id number: 53007 ) |
| Policy contract number | XX39 |
| Policy instance | 1 |
| Insurance contract or identification number | XX39 | | Number of Individuals Covered | 139 | | Insurance policy start date | 2012-09-01 | | Insurance policy end date | 2013-08-31 | | Total amount of commissions paid to insurance broker | USD $33,366 | | Total amount of fees paid to insurance company | USD $14,755 | | 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 | 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 $944,880 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $33,366 | | Amount paid for insurance broker fees | 14755 | | Additional information about fees paid to insurance broker | BROKER FEE | | Insurance broker organization code? | 3 | | Insurance broker name | POTOMAC BASIN GROUP ASSOCIATES |
|
| GHMSI (National Association of Insurance Commissioners NAIC id number: 53007 ) |
| Policy contract number | XX39 |
| Policy instance | 1 |
| Insurance contract or identification number | XX39 | | Number of Individuals Covered | 128 | | Insurance policy start date | 2011-09-01 | | Insurance policy end date | 2012-08-31 | | Total amount of commissions paid to insurance broker | USD $32,909 | | Total amount of fees paid to insurance company | USD $27,065 | | 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 | 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 $931,279 | | 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 | XX39 |
| Policy instance | 1 |
| Insurance contract or identification number | XX39 | | Number of Individuals Covered | 122 | | Insurance policy start date | 2010-09-01 | | Insurance policy end date | 2011-08-31 | | Total amount of commissions paid to insurance broker | USD $35,541 | | Total amount of fees paid to insurance company | USD $26,030 | | 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 | 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 $888,524 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
