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BRITTEN BANNERS, INC. GROUP VISION PLAN 401k Plan overview

Plan NameBRITTEN BANNERS, INC. GROUP VISION PLAN
Plan identification number 501

BRITTEN BANNERS, INC. GROUP VISION PLAN Benefits

401k Plan TypeWelfare Benefit
Plan Features/Benefits
  • Health (other than dental or vision)
  • Life insurance
  • Dental
  • Vision
  • Temporary disability (accident and sickness)
  • Long-term disability cover
  • Death benefits (include travel accident but not life insurance)
  • Other welfare benefit cover

401k Sponsoring company profile

BRITTEN BANNERS, INC. D/B/A BRITTEN, INC. has sponsored the creation of one or more 401k plans.

Company Name:BRITTEN BANNERS, INC. D/B/A BRITTEN, INC.
Employer identification number (EIN):541360557
NAIC Classification:339900

Form 5500 Filing Information

Submission information for form 5500 for 401k plan BRITTEN BANNERS, INC. GROUP VISION PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5012019-09-01PAUL BRITTEN2021-03-04
5012018-09-01PAUL BRITTEN2020-03-26
5012017-09-01
5012016-09-01PAUL BRITTEN
5012015-09-01PAUL BRITTEN
5012014-12-01
5012014-09-01
5012013-12-01
5012013-09-01
5012012-12-01PAUL BRITTEN
5012012-09-01PAUL BRITTEN
5012011-12-01PAUL BRITTEN
5012011-09-01PAUL BRITTEN
5012009-09-01PAUL BRITTEN
5012008-09-01PAUL BRITTEN
5012007-09-01PAUL BRITTEN

Plan Statistics for BRITTEN BANNERS, INC. GROUP VISION PLAN

401k plan membership statisitcs for BRITTEN BANNERS, INC. GROUP VISION PLAN

Measure Date Value
2019: BRITTEN BANNERS, INC. GROUP VISION PLAN 2019 401k membership
Total participants, beginning-of-year2019-09-01239
Total number of active participants reported on line 7a of the Form 55002019-09-01232
Number of retired or separated participants receiving benefits2019-09-0116
Number of other retired or separated participants entitled to future benefits2019-09-010
Total of all active and inactive participants2019-09-01248
2018: BRITTEN BANNERS, INC. GROUP VISION PLAN 2018 401k membership
Total participants, beginning-of-year2018-09-01207
Total number of active participants reported on line 7a of the Form 55002018-09-01232
Number of retired or separated participants receiving benefits2018-09-017
Number of other retired or separated participants entitled to future benefits2018-09-010
Total of all active and inactive participants2018-09-01239
2017: BRITTEN BANNERS, INC. GROUP VISION PLAN 2017 401k membership
Total participants, beginning-of-year2017-09-01224
Total number of active participants reported on line 7a of the Form 55002017-09-01201
Number of retired or separated participants receiving benefits2017-09-016
Number of other retired or separated participants entitled to future benefits2017-09-010
Total of all active and inactive participants2017-09-01207
2016: BRITTEN BANNERS, INC. GROUP VISION PLAN 2016 401k membership
Total participants, beginning-of-year2016-09-01333
Total number of active participants reported on line 7a of the Form 55002016-09-01214
Number of retired or separated participants receiving benefits2016-09-0110
Number of other retired or separated participants entitled to future benefits2016-09-010
Total of all active and inactive participants2016-09-01224
2015: BRITTEN BANNERS, INC. GROUP VISION PLAN 2015 401k membership
Total participants, beginning-of-year2015-09-01359
Total number of active participants reported on line 7a of the Form 55002015-09-01328
Number of retired or separated participants receiving benefits2015-09-015
Number of other retired or separated participants entitled to future benefits2015-09-010
Total of all active and inactive participants2015-09-01333
2014: BRITTEN BANNERS, INC. GROUP VISION PLAN 2014 401k membership
Total participants, beginning-of-year2014-12-01191
Total number of active participants reported on line 7a of the Form 55002014-12-01200
Total of all active and inactive participants2014-12-01200
Total participants, beginning-of-year2014-09-01329
Total number of active participants reported on line 7a of the Form 55002014-09-01359
Total of all active and inactive participants2014-09-01359
2013: BRITTEN BANNERS, INC. GROUP VISION PLAN 2013 401k membership
Total participants, beginning-of-year2013-12-01139
Total number of active participants reported on line 7a of the Form 55002013-12-01191
Total of all active and inactive participants2013-12-01191
Total participants, beginning-of-year2013-09-01263
Total number of active participants reported on line 7a of the Form 55002013-09-01329
Total of all active and inactive participants2013-09-01329
2012: BRITTEN BANNERS, INC. GROUP VISION PLAN 2012 401k membership
Total participants, beginning-of-year2012-12-01113
Total number of active participants reported on line 7a of the Form 55002012-12-01139
Total of all active and inactive participants2012-12-01139
Total participants, beginning-of-year2012-09-01202
Total number of active participants reported on line 7a of the Form 55002012-09-01263
Total of all active and inactive participants2012-09-01263
2011: BRITTEN BANNERS, INC. GROUP VISION PLAN 2011 401k membership
Total participants, beginning-of-year2011-12-010
Total number of active participants reported on line 7a of the Form 55002011-12-01113
Total of all active and inactive participants2011-12-01113
Total participants, beginning-of-year2011-09-01104
Total number of active participants reported on line 7a of the Form 55002011-09-01202
Total of all active and inactive participants2011-09-01202
2009: BRITTEN BANNERS, INC. GROUP VISION PLAN 2009 401k membership
Total participants, beginning-of-year2009-09-01134
Total number of active participants reported on line 7a of the Form 55002009-09-01157
Total of all active and inactive participants2009-09-01157
2008: BRITTEN BANNERS, INC. GROUP VISION PLAN 2008 401k membership
Total participants, beginning-of-year2008-09-01137
Total number of active participants reported on line 7a of the Form 55002008-09-01134
Total of all active and inactive participants2008-09-01134
2007: BRITTEN BANNERS, INC. GROUP VISION PLAN 2007 401k membership
Total participants, beginning-of-year2007-09-010
Total number of active participants reported on line 7a of the Form 55002007-09-01137
Total of all active and inactive participants2007-09-01137

Form 5500 Responses for BRITTEN BANNERS, INC. GROUP VISION PLAN

2019: BRITTEN BANNERS, INC. GROUP VISION PLAN 2019 form 5500 responses
2019-09-01Type of plan entitySingle employer plan
2019-09-01Submission has been amendedNo
2019-09-01This submission is the final filingNo
2019-09-01This return/report is a short plan year return/report (less than 12 months)No
2019-09-01Plan is a collectively bargained planNo
2019-09-01Plan funding arrangement – InsuranceYes
2019-09-01Plan benefit arrangement – InsuranceYes
2018: BRITTEN BANNERS, INC. GROUP VISION PLAN 2018 form 5500 responses
2018-09-01Type of plan entitySingle employer plan
2018-09-01Submission has been amendedNo
2018-09-01This submission is the final filingNo
2018-09-01This return/report is a short plan year return/report (less than 12 months)No
2018-09-01Plan is a collectively bargained planNo
2018-09-01Plan funding arrangement – InsuranceYes
2018-09-01Plan benefit arrangement – InsuranceYes
2017: BRITTEN BANNERS, INC. GROUP VISION PLAN 2017 form 5500 responses
2017-09-01Type of plan entitySingle employer plan
2017-09-01Submission has been amendedNo
2017-09-01This submission is the final filingNo
2017-09-01This return/report is a short plan year return/report (less than 12 months)No
2017-09-01Plan is a collectively bargained planNo
2017-09-01Plan funding arrangement – InsuranceYes
2017-09-01Plan benefit arrangement – InsuranceYes
2016: BRITTEN BANNERS, INC. GROUP VISION PLAN 2016 form 5500 responses
2016-09-01Type of plan entitySingle employer plan
2016-09-01Submission has been amendedNo
2016-09-01This submission is the final filingNo
2016-09-01This return/report is a short plan year return/report (less than 12 months)No
2016-09-01Plan is a collectively bargained planNo
2016-09-01Plan funding arrangement – InsuranceYes
2016-09-01Plan benefit arrangement – InsuranceYes
2015: BRITTEN BANNERS, INC. GROUP VISION PLAN 2015 form 5500 responses
2015-09-01Type of plan entitySingle employer plan
2015-09-01Submission has been amendedNo
2015-09-01This submission is the final filingNo
2015-09-01This return/report is a short plan year return/report (less than 12 months)No
2015-09-01Plan is a collectively bargained planNo
2015-09-01Plan funding arrangement – InsuranceYes
2015-09-01Plan benefit arrangement – InsuranceYes
2014: BRITTEN BANNERS, INC. GROUP VISION PLAN 2014 form 5500 responses
2014-12-01Type of plan entitySingle employer plan
2014-12-01Plan funding arrangement – InsuranceYes
2014-12-01Plan benefit arrangement – InsuranceYes
2014-09-01Type of plan entitySingle employer plan
2014-09-01Plan funding arrangement – InsuranceYes
2014-09-01Plan benefit arrangement – InsuranceYes
2013: BRITTEN BANNERS, INC. GROUP VISION PLAN 2013 form 5500 responses
2013-12-01Type of plan entitySingle employer plan
2013-12-01Plan funding arrangement – InsuranceYes
2013-12-01Plan benefit arrangement – InsuranceYes
2013-09-01Type of plan entitySingle employer plan
2013-09-01Plan funding arrangement – InsuranceYes
2013-09-01Plan benefit arrangement – InsuranceYes
2012: BRITTEN BANNERS, INC. GROUP VISION PLAN 2012 form 5500 responses
2012-12-01Type of plan entitySingle employer plan
2012-12-01Plan funding arrangement – InsuranceYes
2012-12-01Plan benefit arrangement – InsuranceYes
2012-09-01Type of plan entitySingle employer plan
2012-09-01Plan funding arrangement – InsuranceYes
2012-09-01Plan benefit arrangement – InsuranceYes
2011: BRITTEN BANNERS, INC. GROUP VISION PLAN 2011 form 5500 responses
2011-12-01Type of plan entitySingle employer plan
2011-12-01First time form 5500 has been submittedYes
2011-12-01Plan funding arrangement – InsuranceYes
2011-12-01Plan benefit arrangement – InsuranceYes
2011-09-01Type of plan entitySingle employer plan
2011-09-01Plan funding arrangement – InsuranceYes
2011-09-01Plan benefit arrangement – InsuranceYes
2009: BRITTEN BANNERS, INC. GROUP VISION PLAN 2009 form 5500 responses
2009-09-01Type of plan entitySingle employer plan
2009-09-01This submission is the final filingNo
2009-09-01Plan funding arrangement – InsuranceYes
2009-09-01Plan benefit arrangement – InsuranceYes
2008: BRITTEN BANNERS, INC. GROUP VISION PLAN 2008 form 5500 responses
2008-09-01Type of plan entitySingle employer plan
2008-09-01Plan funding arrangement – InsuranceYes
2008-09-01Plan benefit arrangement – InsuranceYes
2007: BRITTEN BANNERS, INC. GROUP VISION PLAN 2007 form 5500 responses
2007-09-01Type of plan entitySingle employer plan
2007-09-01First time form 5500 has been submittedYes
2007-09-01Plan funding arrangement – InsuranceYes
2007-09-01Plan benefit arrangement – InsuranceYes

Insurance Providers Used on plan

DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 )
Policy contract number0002640
Policy instance 3
Insurance contract or identification number0002640
Number of Individuals Covered259
Insurance policy start date2019-09-01
Insurance policy end date2020-08-31
Total amount of commissions paid to insurance brokerUSD $4,900
Total amount of fees paid to insurance companyUSD $214
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,900
Amount paid for insurance broker fees214
Additional information about fees paid to insurance brokerSUPPLEMENTAL COMPENSATION
Insurance broker organization code?3
BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 )
Policy contract number187381
Policy instance 1
Insurance contract or identification number187381
Number of Individuals Covered12
Insurance policy start date2019-09-01
Insurance policy end date2020-08-31
Total amount of commissions paid to insurance brokerUSD $740
Total amount of fees paid to insurance companyUSD $38
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $740
Amount paid for insurance broker fees38
Additional information about fees paid to insurance brokerSUPPLEMENTAL COMPENSATION
Insurance broker organization code?3
BLUE CARE NETWORK OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 95610 )
Policy contract number187381
Policy instance 2
Insurance contract or identification number187381
Number of Individuals Covered257
Insurance policy start date2019-09-01
Insurance policy end date2020-08-31
Total amount of commissions paid to insurance brokerUSD $30,624
Total amount of fees paid to insurance companyUSD $1,097
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $30,624
Amount paid for insurance broker fees1097
Additional information about fees paid to insurance brokerSUPPLEMENTAL COMPENSATION
Insurance broker organization code?3
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number12249510
Policy instance 10
Insurance contract or identification number12249510
Number of Individuals Covered140
Insurance policy start date2019-09-01
Insurance policy end date2020-08-31
Total amount of commissions paid to insurance brokerUSD $1,021
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $18,566
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,021
Insurance broker organization code?3
PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )
Policy contract number0009925019
Policy instance 4
Insurance contract or identification number0009925019
Number of Individuals Covered21
Insurance policy start date2019-09-01
Insurance policy end date2020-08-31
Total amount of commissions paid to insurance brokerUSD $370
Total amount of fees paid to insurance companyUSD $2
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $5,459
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $150
Insurance broker organization code?3
Amount paid for insurance broker fees2
Additional information about fees paid to insurance brokerSUPPLEMENTAL COMPENSATION
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number413391
Policy instance 5
Insurance contract or identification number413391
Number of Individuals Covered30
Insurance policy start date2019-09-01
Insurance policy end date2020-08-31
Total amount of commissions paid to insurance brokerUSD $1,575
Total amount of fees paid to insurance companyUSD $210
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $10,564
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,575
Amount paid for insurance broker fees210
Additional information about fees paid to insurance brokerSUPPLEMENTAL COMPENSATION
Insurance broker organization code?3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number415328
Policy instance 6
Insurance contract or identification number415328
Number of Individuals Covered232
Insurance policy start date2019-09-01
Insurance policy end date2020-08-31
Total amount of commissions paid to insurance brokerUSD $915
Total amount of fees paid to insurance companyUSD $183
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL 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 CarrierUSD $9,154
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $915
Amount paid for insurance broker fees183
Additional information about fees paid to insurance brokerSUPPLEMENTAL COMPENSATION
Insurance broker organization code?3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number415329
Policy instance 7
Insurance contract or identification number415329
Number of Individuals Covered67
Insurance policy start date2019-09-01
Insurance policy end date2020-08-31
Total amount of commissions paid to insurance brokerUSD $2,328
Total amount of fees paid to insurance companyUSD $552
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $27,934
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,328
Amount paid for insurance broker fees552
Additional information about fees paid to insurance brokerSUPPLEMENTAL COMPENSATION
Insurance broker organization code?3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number415330
Policy instance 8
Insurance contract or identification number415330
Number of Individuals Covered106
Insurance policy start date2019-09-01
Insurance policy end date2020-08-31
Total amount of commissions paid to insurance brokerUSD $4,115
Total amount of fees paid to insurance companyUSD $549
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL 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 CarrierUSD $27,127
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,115
Amount paid for insurance broker fees549
Additional information about fees paid to insurance brokerSUPPLEMENTAL COMPENSATION
Insurance broker organization code?3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract numberR0506550
Policy instance 9
Insurance contract or identification numberR0506550
Number of Individuals Covered149
Insurance policy start date2019-09-01
Insurance policy end date2020-08-31
Total amount of commissions paid to insurance brokerUSD $2,145
Total amount of fees paid to insurance companyUSD $10
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedCRITICAL ILLNESS, ACCIDENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $34,561
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,018
Insurance broker organization code?3
Amount paid for insurance broker fees10
Additional information about fees paid to insurance brokerSUPPLEMENTAL COMPENSATION
DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 )
Policy contract number0002640
Policy instance 3
Insurance contract or identification number0002640
Number of Individuals Covered270
Insurance policy start date2018-09-01
Insurance policy end date2019-08-31
Total amount of commissions paid to insurance brokerUSD $5,313
Total amount of fees paid to insurance companyUSD $223
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,313
Amount paid for insurance broker fees223
Additional information about fees paid to insurance brokerSUPPLEMENTAL COMPENSATION
Insurance broker organization code?3
BLUE CARE NETWORK OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 95610 )
Policy contract number187381
Policy instance 2
Insurance contract or identification number187381
Number of Individuals Covered289
Insurance policy start date2018-09-01
Insurance policy end date2019-08-31
Total amount of commissions paid to insurance brokerUSD $52,616
Total amount of fees paid to insurance companyUSD $8,630
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $52,616
Amount paid for insurance broker fees8630
Additional information about fees paid to insurance brokerSUPPLEMENTAL COMPENSATION
Insurance broker organization code?3
BLUE CROSS BLUE SHIELD OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54291 )
Policy contract number187381
Policy instance 1
Insurance contract or identification number187381
Number of Individuals Covered8
Insurance policy start date2018-09-01
Insurance policy end date2019-08-31
Total amount of commissions paid to insurance brokerUSD $1,010
Total amount of fees paid to insurance companyUSD $190
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,010
Amount paid for insurance broker fees190
Additional information about fees paid to insurance brokerSUPPLEMENTAL COMPENSATION
Insurance broker organization code?3
PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )
Policy contract number0009925019
Policy instance 4
Insurance contract or identification number0009925019
Number of Individuals Covered33
Insurance policy start date2018-09-01
Insurance policy end date2019-08-31
Total amount of commissions paid to insurance brokerUSD $2,332
Total amount of fees paid to insurance companyUSD $95
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $8,845
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $863
Insurance broker organization code?3
Amount paid for insurance broker fees44
Additional information about fees paid to insurance brokerSUPPLEMENTAL COMPENSATION
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number413391
Policy instance 5
Insurance contract or identification number413391
Number of Individuals Covered30
Insurance policy start date2018-09-01
Insurance policy end date2019-08-31
Total amount of commissions paid to insurance brokerUSD $1,564
Total amount of fees paid to insurance companyUSD $208
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $10,487
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,564
Amount paid for insurance broker fees208
Additional information about fees paid to insurance brokerSUPPLEMENTAL COMPENSATION
Insurance broker organization code?3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number415328
Policy instance 6
Insurance contract or identification number415328
Number of Individuals Covered232
Insurance policy start date2018-09-01
Insurance policy end date2019-08-31
Total amount of commissions paid to insurance brokerUSD $946
Total amount of fees paid to insurance companyUSD $189
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL 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 CarrierUSD $9,461
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $946
Amount paid for insurance broker fees189
Additional information about fees paid to insurance brokerSUPPLEMENTAL COMPENSATION
Insurance broker organization code?3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number415329
Policy instance 7
Insurance contract or identification number415329
Number of Individuals Covered71
Insurance policy start date2018-09-01
Insurance policy end date2019-08-31
Total amount of commissions paid to insurance brokerUSD $2,371
Total amount of fees paid to insurance companyUSD $575
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $29,091
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,371
Amount paid for insurance broker fees575
Additional information about fees paid to insurance brokerSUPPLEMENTAL COMPENSATION
Insurance broker organization code?3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number415330
Policy instance 8
Insurance contract or identification number415330
Number of Individuals Covered102
Insurance policy start date2018-09-01
Insurance policy end date2019-08-31
Total amount of commissions paid to insurance brokerUSD $3,740
Total amount of fees paid to insurance companyUSD $499
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL 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 CarrierUSD $25,317
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,740
Amount paid for insurance broker fees499
Additional information about fees paid to insurance brokerSUPPLEMENTAL COMPENSATION
Insurance broker organization code?3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract numberR0506550
Policy instance 9
Insurance contract or identification numberR0506550
Number of Individuals Covered176
Insurance policy start date2018-09-01
Insurance policy end date2019-08-31
Total amount of commissions paid to insurance brokerUSD $6,753
Total amount of fees paid to insurance companyUSD $209
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedCRITICAL ILLNESS, ACCIDENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $41,704
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,639
Insurance broker organization code?3
Amount paid for insurance broker fees150
Additional information about fees paid to insurance brokerSUPPLEMENTAL COMPENSATION
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number12249510
Policy instance 10
Insurance contract or identification number12249510
Number of Individuals Covered156
Insurance policy start date2018-09-01
Insurance policy end date2019-08-31
Total amount of commissions paid to insurance brokerUSD $1,157
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $21,690
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,157
Insurance broker organization code?3
DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 )
Policy contract number0002640
Policy instance 1
Insurance contract or identification number0002640
Number of Individuals Covered283
Insurance policy start date2017-09-01
Insurance policy end date2018-08-31
Total amount of commissions paid to insurance brokerUSD $5,842
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
PRIORITY HEALTH (National Association of Insurance Commissioners NAIC id number: 95561 )
Policy contract number745110
Policy instance 2
Insurance contract or identification number745110
Number of Individuals Covered308
Insurance policy start date2017-09-01
Insurance policy end date2018-08-31
Total amount of commissions paid to insurance brokerUSD $19,689
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $1,313,723
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
PRIORITY HEALTH (National Association of Insurance Commissioners NAIC id number: 12208 )
Policy contract number745110
Policy instance 3
Insurance contract or identification number745110
Number of Individuals Covered14
Insurance policy start date2017-09-01
Insurance policy end date2018-08-31
Total amount of commissions paid to insurance brokerUSD $997
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $66,478
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number413391
Policy instance 4
Insurance contract or identification number413391
Number of Individuals Covered13
Insurance policy start date2017-09-01
Insurance policy end date2018-08-31
Total amount of commissions paid to insurance brokerUSD $988
Total amount of fees paid to insurance companyUSD $132
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $6,496
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number415328
Policy instance 5
Insurance contract or identification number415328
Number of Individuals Covered201
Insurance policy start date2017-09-01
Insurance policy end date2018-08-31
Total amount of commissions paid to insurance brokerUSD $969
Total amount of fees paid to insurance companyUSD $194
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL 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 CarrierUSD $9,694
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number415329
Policy instance 6
Insurance contract or identification number415329
Number of Individuals Covered49
Insurance policy start date2017-09-01
Insurance policy end date2018-08-31
Total amount of commissions paid to insurance brokerUSD $2,403
Total amount of fees paid to insurance companyUSD $573
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $27,858
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number415330
Policy instance 7
Insurance contract or identification number415330
Number of Individuals Covered93
Insurance policy start date2017-09-01
Insurance policy end date2018-08-31
Total amount of commissions paid to insurance brokerUSD $4,108
Total amount of fees paid to insurance companyUSD $548
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL 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 CarrierUSD $27,454
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract numberR0506550
Policy instance 8
Insurance contract or identification numberR0506550
Number of Individuals Covered128
Insurance policy start date2017-09-01
Insurance policy end date2018-08-31
Total amount of commissions paid to insurance brokerUSD $10,643
Total amount of fees paid to insurance companyUSD $1,330
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedCRITICAL ILLNESS, ACCIDENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $44,741
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number12249510
Policy instance 9
Insurance contract or identification number12249510
Number of Individuals Covered156
Insurance policy start date2017-09-01
Insurance policy end date2018-08-31
Total amount of commissions paid to insurance brokerUSD $1,146
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $21,523
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number12249510
Policy instance 4
Insurance contract or identification number12249510
Number of Individuals Covered157
Insurance policy start date2015-09-01
Insurance policy end date2016-08-31
Total amount of commissions paid to insurance brokerUSD $1,202
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $23,776
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $743
Insurance broker organization code?3
Insurance broker nameMARSH & MCLENNAN AGENCY LLC
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number415330
Policy instance 7
Insurance contract or identification number415330
Number of Individuals Covered129
Insurance policy start date2015-09-01
Insurance policy end date2016-08-31
Total amount of commissions paid to insurance brokerUSD $5,331
Total amount of fees paid to insurance companyUSD $272
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL 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 CarrierUSD $36,621
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,291
Insurance broker organization code?3
Amount paid for insurance broker fees272
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
Insurance broker nameMARSH & MCLENNAN
PRIORITY HEALTH (National Association of Insurance Commissioners NAIC id number: 95561 )
Policy contract number745110
Policy instance 1
Insurance contract or identification number745110
Number of Individuals Covered350
Insurance policy start date2015-09-01
Insurance policy end date2016-08-31
Total amount of commissions paid to insurance brokerUSD $16,858
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $1,240,823
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $9,478
Insurance broker organization code?3
Insurance broker nameTHOMAS P. MCGRAW
PRIORITY HEALTH (National Association of Insurance Commissioners NAIC id number: 12208 )
Policy contract number745110
Policy instance 2
Insurance contract or identification number745110
Number of Individuals Covered9
Insurance policy start date2015-09-01
Insurance policy end date2016-08-31
Total amount of commissions paid to insurance brokerUSD $777
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $55,538
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $561
Insurance broker organization code?3
Insurance broker nameTHOMAS P. MCGRAW
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract numberR0506550
Policy instance 8
Insurance contract or identification numberR0506550
Number of Individuals Covered57
Insurance policy start date2015-09-01
Insurance policy end date2016-08-31
Total amount of commissions paid to insurance brokerUSD $2,669
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedCRITICAL ILLNESS; ACCIDENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $23,585
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,868
Insurance broker organization code?3
Insurance broker nameSMITH, THOMAS, CHRISTOPHER
DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 )
Policy contract number0002640
Policy instance 3
Insurance contract or identification number0002640
Number of Individuals Covered358
Insurance policy start date2015-09-01
Insurance policy end date2016-08-31
Total amount of commissions paid to insurance brokerUSD $6,751
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,327
Insurance broker organization code?3
Insurance broker nameWRIGHT & ASSOCIATES
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number415328
Policy instance 5
Insurance contract or identification number415328
Number of Individuals Covered328
Insurance policy start date2015-09-01
Insurance policy end date2016-08-31
Total amount of commissions paid to insurance brokerUSD $1,052
Total amount of fees paid to insurance companyUSD $83
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL 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 CarrierUSD $11,272
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $636
Insurance broker organization code?3
Amount paid for insurance broker fees83
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
Insurance broker nameMARSH & MCLENNAN
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number415329
Policy instance 6
Insurance contract or identification number415329
Number of Individuals Covered90
Insurance policy start date2015-09-01
Insurance policy end date2016-08-31
Total amount of commissions paid to insurance brokerUSD $2,315
Total amount of fees paid to insurance companyUSD $219
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $27,552
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,548
Insurance broker organization code?3
Amount paid for insurance broker fees219
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
Insurance broker nameMARSH & MCLENNAN
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number12249510
Policy instance 1
Insurance contract or identification number12249510
Number of Individuals Covered200
Insurance policy start date2014-12-01
Insurance policy end date2015-11-30
Total amount of commissions paid to insurance brokerUSD $1,318
Total amount of fees paid to insurance companyUSD $2
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $27,061
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,318
Amount paid for insurance broker fees2
Insurance broker organization code?3
Insurance broker nameMATRIX SURPLUS AGENCY, INC.
PRIORITY HEALTH (National Association of Insurance Commissioners NAIC id number: 95561 )
Policy contract number745110 S007
Policy instance 7
Insurance contract or identification number745110 S007
Number of Individuals Covered23
Insurance policy start date2014-09-01
Insurance policy end date2015-08-31
Total amount of commissions paid to insurance brokerUSD $625
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $42,255
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $625
Insurance broker organization code?3
Insurance broker nameCHUCK RODECK
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number415330
Policy instance 6
Insurance contract or identification number415330
Number of Individuals Covered173
Insurance policy start date2014-09-01
Insurance policy end date2015-08-31
Total amount of commissions paid to insurance brokerUSD $5,450
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Life Insurance Welfare BenefitYes
Other welfare benefits providedADD
Welfare Benefit Premiums Paid to CarrierUSD $37,246
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,450
Insurance broker organization code?3
Insurance broker nameMATRIX SURPLUS AGENCY
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number415328
Policy instance 5
Insurance contract or identification number415328
Number of Individuals Covered347
Insurance policy start date2014-09-01
Insurance policy end date2015-08-31
Total amount of commissions paid to insurance brokerUSD $1,178
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Life Insurance Welfare BenefitYes
Other welfare benefits providedADD
Welfare Benefit Premiums Paid to CarrierUSD $11,778
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,178
Insurance broker organization code?3
Insurance broker nameMATRIX SURPLUS AGENCY
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number415329
Policy instance 8
Insurance contract or identification number415329
Number of Individuals Covered82
Insurance policy start date2014-09-01
Insurance policy end date2015-08-31
Total amount of commissions paid to insurance brokerUSD $2,634
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $33,771
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,634
Insurance broker organization code?3
Insurance broker nameMATRIX SURPLUS AGENCY
PRIORITY HEALTH (National Association of Insurance Commissioners NAIC id number: 95561 )
Policy contract number745110 S005
Policy instance 4
Insurance contract or identification number745110 S005
Number of Individuals Covered56
Insurance policy start date2014-09-01
Insurance policy end date2015-08-31
Total amount of commissions paid to insurance brokerUSD $1,963
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $133,996
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,963
Insurance broker organization code?3
Insurance broker nameCHUCK RODECK
PRIORITY HEALTH (National Association of Insurance Commissioners NAIC id number: 12208 )
Policy contract number745110 S003
Policy instance 2
Insurance contract or identification number745110 S003
Number of Individuals Covered13
Insurance policy start date2014-09-01
Insurance policy end date2015-08-31
Total amount of commissions paid to insurance brokerUSD $847
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $57,244
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $847
Insurance broker organization code?3
Insurance broker nameCHUCK RODECK
PRIORITY HEALTH (National Association of Insurance Commissioners NAIC id number: 95561 )
Policy contract number745110 S002
Policy instance 1
Insurance contract or identification number745110 S002
Number of Individuals Covered209
Insurance policy start date2014-09-01
Insurance policy end date2015-08-31
Total amount of commissions paid to insurance brokerUSD $10,970
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $743,227
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $10,970
Insurance broker organization code?3
Insurance broker nameCHUCK RODECK
PRIORITY HEALTH (National Association of Insurance Commissioners NAIC id number: 95561 )
Policy contract number745110 S003
Policy instance 3
Insurance contract or identification number745110 S003
Number of Individuals Covered58
Insurance policy start date2014-09-01
Insurance policy end date2015-08-31
Total amount of commissions paid to insurance brokerUSD $2,816
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $190,967
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,816
Insurance broker organization code?3
Insurance broker nameCHUCK RODECK
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number12249510
Policy instance 1
Insurance contract or identification number12249510
Number of Individuals Covered191
Insurance policy start date2013-12-01
Insurance policy end date2014-11-30
Total amount of commissions paid to insurance brokerUSD $1,141
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $21,182
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,141
Insurance broker organization code?3
Insurance broker nameMATRIX SURPLUS AGENCY, INC.
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract numberRC506550
Policy instance 7
Insurance contract or identification numberRC506550
Number of Individuals Covered54
Insurance policy start date2013-09-01
Insurance policy end date2014-08-31
Total amount of commissions paid to insurance brokerUSD $9,109
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Other welfare benefits providedGCI EE PAY, GRP ACC VOL 11
Welfare Benefit Premiums Paid to CarrierUSD $12,627
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6,378
Insurance broker organization code?3
Insurance broker nameSMITH, THOMAS, CHRISTOPHER
PRIORITY HEALTH (National Association of Insurance Commissioners NAIC id number: 95561 )
Policy contract number745110 S005
Policy instance 4
Insurance contract or identification number745110 S005
Number of Individuals Covered27
Insurance policy start date2013-09-01
Insurance policy end date2014-08-31
Total amount of commissions paid to insurance brokerUSD $1,420
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $95,559
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,420
Insurance broker organization code?3
Insurance broker nameCHUCK RODECK
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number415328
Policy instance 5
Insurance contract or identification number415328
Number of Individuals Covered618
Insurance policy start date2013-09-01
Insurance policy end date2014-08-31
Total amount of commissions paid to insurance brokerUSD $1,085
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Life Insurance Welfare BenefitYes
Other welfare benefits providedADD
Welfare Benefit Premiums Paid to CarrierUSD $7,853
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,085
Insurance broker organization code?3
Insurance broker nameMATRIX SURPLUS AGENCY
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract numberE3084274
Policy instance 6
Insurance contract or identification numberE3084274
Number of Individuals Covered29
Insurance policy start date2013-09-01
Insurance policy end date2014-08-31
Total amount of commissions paid to insurance brokerUSD $280
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $3,663
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $164
Insurance broker organization code?3
Insurance broker nameJAMES TAYLOR
PRIORITY HEALTH (National Association of Insurance Commissioners NAIC id number: 12208 )
Policy contract number745110 S003
Policy instance 2
Insurance contract or identification number745110 S003
Number of Individuals Covered15
Insurance policy start date2013-09-01
Insurance policy end date2014-08-31
Total amount of commissions paid to insurance brokerUSD $916
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $61,665
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $916
Insurance broker organization code?3
Insurance broker nameCHUCK RODECK
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number415330
Policy instance 8
Insurance contract or identification number415330
Number of Individuals Covered150
Insurance policy start date2013-09-01
Insurance policy end date2014-08-31
Total amount of commissions paid to insurance brokerUSD $3,676
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Life Insurance Welfare BenefitYes
Other welfare benefits providedADD
Welfare Benefit Premiums Paid to CarrierUSD $22,508
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,676
Insurance broker nameMATRIX SURPLUS AGENCY
PRIORITY HEALTH (National Association of Insurance Commissioners NAIC id number: 95561 )
Policy contract number745110 S002
Policy instance 1
Insurance contract or identification number745110 S002
Number of Individuals Covered230
Insurance policy start date2013-09-01
Insurance policy end date2014-08-31
Total amount of commissions paid to insurance brokerUSD $11,982
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $807,660
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $11,982
Insurance broker organization code?3
Insurance broker nameCHUCK RODECK
PRIORITY HEALTH (National Association of Insurance Commissioners NAIC id number: 95561 )
Policy contract number745110 S003
Policy instance 3
Insurance contract or identification number745110 S003
Number of Individuals Covered57
Insurance policy start date2013-09-01
Insurance policy end date2014-08-31
Total amount of commissions paid to insurance brokerUSD $1,705
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $115,251
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,705
Insurance broker organization code?3
Insurance broker nameCHUCK RODECK
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number12249510
Policy instance 1
Insurance contract or identification number12249510
Number of Individuals Covered139
Insurance policy start date2012-12-01
Insurance policy end date2013-11-30
Total amount of commissions paid to insurance brokerUSD $950
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $15,625
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $950
Insurance broker organization code?3
Insurance broker nameMATRIX SURPLUS AGENCY, INC.
PRIORITY HEALTH (National Association of Insurance Commissioners NAIC id number: 95561 )
Policy contract number745110 S003
Policy instance 3
Insurance contract or identification number745110 S003
Number of Individuals Covered15
Insurance policy start date2012-09-01
Insurance policy end date2013-08-31
Total amount of commissions paid to insurance brokerUSD $823
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $54,855
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $823
Insurance broker organization code?3
Insurance broker nameCHUCK RODECK
PRIORITY HEALTH (National Association of Insurance Commissioners NAIC id number: 95561 )
Policy contract number745110 S002
Policy instance 1
Insurance contract or identification number745110 S002
Number of Individuals Covered248
Insurance policy start date2012-09-01
Insurance policy end date2013-08-31
Total amount of commissions paid to insurance brokerUSD $12,792
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $852,790
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $12,792
Insurance broker organization code?3
Insurance broker nameCHUCK RODECK
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract numberE3084274
Policy instance 2
Insurance contract or identification numberE3084274
Number of Individuals Covered29
Insurance policy start date2012-09-01
Insurance policy end date2013-08-31
Total amount of commissions paid to insurance brokerUSD $2,105
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $20,616
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,194
Insurance broker organization code?3
Insurance broker nameJAMES TAYLOR
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number12249510
Policy instance 1
Insurance contract or identification number12249510
Number of Individuals Covered113
Insurance policy start date2011-12-01
Insurance policy end date2012-11-30
Total amount of commissions paid to insurance brokerUSD $887
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $13,839
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
PRIORITY HEALTH (National Association of Insurance Commissioners NAIC id number: 95561 )
Policy contract number745110
Policy instance 1
Insurance contract or identification number745110
Insurance policy start date2011-09-01
Insurance policy end date2012-08-31
Total amount of commissions paid to insurance brokerUSD $9,783
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $652,183
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
PRIORITY HEALTH (National Association of Insurance Commissioners NAIC id number: 95561 )
Policy contract number745110
Policy instance 1
Insurance contract or identification number745110
Number of Individuals Covered104
Insurance policy start date2010-09-01
Insurance policy end date2011-08-31
Total amount of commissions paid to insurance brokerUSD $7,315
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $487,659
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number000010093482
Policy instance 1
Insurance contract or identification number000010093482
Number of Individuals Covered134
Insurance policy start date2008-09-01
Insurance policy end date2009-08-31
Total amount of commissions paid to insurance brokerUSD $799
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Life Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $6,262
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number00001D015943
Policy instance 2
Insurance contract or identification number00001D015943
Number of Individuals Covered123
Insurance policy start date2008-09-01
Insurance policy end date2009-08-31
Total amount of commissions paid to insurance brokerUSD $2,962
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $74,157
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number00001D015943
Policy instance 2
Insurance contract or identification number00001D015943
Number of Individuals Covered118
Insurance policy start date2007-09-01
Insurance policy end date2008-08-31
Total amount of commissions paid to insurance brokerUSD $2,804
Total amount of fees paid to insurance companyUSD $266
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $65,795
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number40000100007021
Policy instance 3
Insurance contract or identification number40000100007021
Number of Individuals Covered132
Insurance policy start date2007-09-01
Insurance policy end date2007-08-31
Total amount of commissions paid to insurance brokerUSD $1,512
Total amount of fees paid to insurance companyUSD $161
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Life Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $10,080
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number000010093482
Policy instance 1
Insurance contract or identification number000010093482
Number of Individuals Covered132
Insurance policy start date2007-09-01
Insurance policy end date2008-08-31
Total amount of commissions paid to insurance brokerUSD $789
Total amount of fees paid to insurance companyUSD $101
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Life Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $6,200
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No

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