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PEPSI-COLA BOTTLING COMPANY OF HICKORY, NC, INC. 401k Plan overview

Plan NamePEPSI-COLA BOTTLING COMPANY OF HICKORY, NC, INC.
Plan identification number 501

PEPSI-COLA BOTTLING COMPANY OF HICKORY, NC, INC. 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)

401k Sponsoring company profile

PEPSI-COLA BOTTLING COMPANY OF HICKORY, N.C., INC. has sponsored the creation of one or more 401k plans.

Company Name:PEPSI-COLA BOTTLING COMPANY OF HICKORY, N.C., INC.
Employer identification number (EIN):560585594
NAIC Classification:424400

Form 5500 Filing Information

Submission information for form 5500 for 401k plan PEPSI-COLA BOTTLING COMPANY OF HICKORY, NC, INC.

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5012022-04-01KEVIN KIRBY2023-10-12
5012021-04-01KEVIN KIRBY2022-10-03
5012020-04-01KEVIN C. KIRBY2021-10-06
5012019-04-01KEVIN C. KIRBY2020-10-07
5012018-04-01KEVIN C. KIRBY2019-08-16
5012017-04-01
5012016-04-01
5012015-04-01KEVIN C KIRBY
5012014-04-01KEVIN C. KIRBY
5012013-04-01KEVIN C KIRBY
5012012-04-01KEVIN C. KIRBY
5012011-04-01ERIC S. PLEMMONS
5012009-04-01ERIC S. PLEMMONS
5012008-05-01ERIC S. PLEMMONS
5012008-05-01ERIC S. PLEMMONS

Plan Statistics for PEPSI-COLA BOTTLING COMPANY OF HICKORY, NC, INC.

401k plan membership statisitcs for PEPSI-COLA BOTTLING COMPANY OF HICKORY, NC, INC.

Measure Date Value
2022: PEPSI-COLA BOTTLING COMPANY OF HICKORY, NC, INC. 2022 401k membership
Total participants, beginning-of-year2022-04-01304
Total number of active participants reported on line 7a of the Form 55002022-04-01321
Number of retired or separated participants receiving benefits2022-04-013
Number of other retired or separated participants entitled to future benefits2022-04-0113
Total of all active and inactive participants2022-04-01337
Number of employers contributing to the scheme2022-04-010
2021: PEPSI-COLA BOTTLING COMPANY OF HICKORY, NC, INC. 2021 401k membership
Total participants, beginning-of-year2021-04-01296
Total number of active participants reported on line 7a of the Form 55002021-04-01286
Number of retired or separated participants receiving benefits2021-04-013
Number of other retired or separated participants entitled to future benefits2021-04-0116
Total of all active and inactive participants2021-04-01305
Number of employers contributing to the scheme2021-04-010
2020: PEPSI-COLA BOTTLING COMPANY OF HICKORY, NC, INC. 2020 401k membership
Total participants, beginning-of-year2020-04-01311
Total number of active participants reported on line 7a of the Form 55002020-04-01297
Number of retired or separated participants receiving benefits2020-04-012
Number of other retired or separated participants entitled to future benefits2020-04-015
Total of all active and inactive participants2020-04-01304
Number of employers contributing to the scheme2020-04-010
2019: PEPSI-COLA BOTTLING COMPANY OF HICKORY, NC, INC. 2019 401k membership
Total participants, beginning-of-year2019-04-01307
Total number of active participants reported on line 7a of the Form 55002019-04-01304
Number of retired or separated participants receiving benefits2019-04-017
Number of other retired or separated participants entitled to future benefits2019-04-019
Total of all active and inactive participants2019-04-01320
Number of employers contributing to the scheme2019-04-010
2018: PEPSI-COLA BOTTLING COMPANY OF HICKORY, NC, INC. 2018 401k membership
Total participants, beginning-of-year2018-04-01300
Total number of active participants reported on line 7a of the Form 55002018-04-01298
Number of retired or separated participants receiving benefits2018-04-014
Number of other retired or separated participants entitled to future benefits2018-04-016
Total of all active and inactive participants2018-04-01308
Number of employers contributing to the scheme2018-04-010
2017: PEPSI-COLA BOTTLING COMPANY OF HICKORY, NC, INC. 2017 401k membership
Total participants, beginning-of-year2017-04-01304
Total number of active participants reported on line 7a of the Form 55002017-04-01299
Number of retired or separated participants receiving benefits2017-04-015
Number of other retired or separated participants entitled to future benefits2017-04-015
Total of all active and inactive participants2017-04-01309
2016: PEPSI-COLA BOTTLING COMPANY OF HICKORY, NC, INC. 2016 401k membership
Total participants, beginning-of-year2016-04-01306
Total number of active participants reported on line 7a of the Form 55002016-04-01294
Number of retired or separated participants receiving benefits2016-04-017
Number of other retired or separated participants entitled to future benefits2016-04-013
Total of all active and inactive participants2016-04-01304
2015: PEPSI-COLA BOTTLING COMPANY OF HICKORY, NC, INC. 2015 401k membership
Total participants, beginning-of-year2015-04-01286
Total number of active participants reported on line 7a of the Form 55002015-04-01297
Number of retired or separated participants receiving benefits2015-04-015
Number of other retired or separated participants entitled to future benefits2015-04-014
Total of all active and inactive participants2015-04-01306
2014: PEPSI-COLA BOTTLING COMPANY OF HICKORY, NC, INC. 2014 401k membership
Total participants, beginning-of-year2014-04-01286
Total number of active participants reported on line 7a of the Form 55002014-04-01269
Number of retired or separated participants receiving benefits2014-04-013
Number of other retired or separated participants entitled to future benefits2014-04-0110
Total of all active and inactive participants2014-04-01282
2013: PEPSI-COLA BOTTLING COMPANY OF HICKORY, NC, INC. 2013 401k membership
Total participants, beginning-of-year2013-04-01296
Total number of active participants reported on line 7a of the Form 55002013-04-01285
Number of retired or separated participants receiving benefits2013-04-019
Number of other retired or separated participants entitled to future benefits2013-04-012
Total of all active and inactive participants2013-04-01296
2012: PEPSI-COLA BOTTLING COMPANY OF HICKORY, NC, INC. 2012 401k membership
Total participants, beginning-of-year2012-04-01312
Total number of active participants reported on line 7a of the Form 55002012-04-01305
Number of retired or separated participants receiving benefits2012-04-019
Number of other retired or separated participants entitled to future benefits2012-04-010
Total of all active and inactive participants2012-04-01314
2011: PEPSI-COLA BOTTLING COMPANY OF HICKORY, NC, INC. 2011 401k membership
Total participants, beginning-of-year2011-04-01328
Total number of active participants reported on line 7a of the Form 55002011-04-01305
Number of retired or separated participants receiving benefits2011-04-018
Number of other retired or separated participants entitled to future benefits2011-04-010
Total of all active and inactive participants2011-04-01313
2009: PEPSI-COLA BOTTLING COMPANY OF HICKORY, NC, INC. 2009 401k membership
Total participants, beginning-of-year2009-04-01334
Total number of active participants reported on line 7a of the Form 55002009-04-01328
Number of retired or separated participants receiving benefits2009-04-010
Number of other retired or separated participants entitled to future benefits2009-04-010
Total of all active and inactive participants2009-04-01328
2008: PEPSI-COLA BOTTLING COMPANY OF HICKORY, NC, INC. 2008 401k membership
Total participants, beginning-of-year2008-05-01334
Total number of active participants reported on line 7a of the Form 55002008-05-01334
Number of retired or separated participants receiving benefits2008-05-010
Number of other retired or separated participants entitled to future benefits2008-05-010
Total of all active and inactive participants2008-05-01334

Form 5500 Responses for PEPSI-COLA BOTTLING COMPANY OF HICKORY, NC, INC.

2022: PEPSI-COLA BOTTLING COMPANY OF HICKORY, NC, INC. 2022 form 5500 responses
2022-04-01Type of plan entitySingle employer plan
2022-04-01Plan funding arrangement – InsuranceYes
2022-04-01Plan funding arrangement – General assets of the sponsorYes
2022-04-01Plan benefit arrangement – InsuranceYes
2022-04-01Plan benefit arrangement – General assets of the sponsorYes
2021: PEPSI-COLA BOTTLING COMPANY OF HICKORY, NC, INC. 2021 form 5500 responses
2021-04-01Type of plan entitySingle employer plan
2021-04-01Plan funding arrangement – InsuranceYes
2021-04-01Plan funding arrangement – General assets of the sponsorYes
2021-04-01Plan benefit arrangement – InsuranceYes
2021-04-01Plan benefit arrangement – General assets of the sponsorYes
2020: PEPSI-COLA BOTTLING COMPANY OF HICKORY, NC, INC. 2020 form 5500 responses
2020-04-01Type of plan entitySingle employer plan
2020-04-01Plan funding arrangement – InsuranceYes
2020-04-01Plan funding arrangement – General assets of the sponsorYes
2020-04-01Plan benefit arrangement – InsuranceYes
2020-04-01Plan benefit arrangement – General assets of the sponsorYes
2019: PEPSI-COLA BOTTLING COMPANY OF HICKORY, NC, INC. 2019 form 5500 responses
2019-04-01Type of plan entitySingle employer plan
2019-04-01Plan funding arrangement – InsuranceYes
2019-04-01Plan funding arrangement – General assets of the sponsorYes
2019-04-01Plan benefit arrangement – InsuranceYes
2019-04-01Plan benefit arrangement – General assets of the sponsorYes
2018: PEPSI-COLA BOTTLING COMPANY OF HICKORY, NC, INC. 2018 form 5500 responses
2018-04-01Type of plan entitySingle employer plan
2018-04-01Plan funding arrangement – InsuranceYes
2018-04-01Plan funding arrangement – General assets of the sponsorYes
2018-04-01Plan benefit arrangement – InsuranceYes
2018-04-01Plan benefit arrangement – General assets of the sponsorYes
2017: PEPSI-COLA BOTTLING COMPANY OF HICKORY, NC, INC. 2017 form 5500 responses
2017-04-01Type of plan entitySingle employer plan
2017-04-01Plan funding arrangement – InsuranceYes
2017-04-01Plan funding arrangement – General assets of the sponsorYes
2017-04-01Plan benefit arrangement – InsuranceYes
2017-04-01Plan benefit arrangement – General assets of the sponsorYes
2016: PEPSI-COLA BOTTLING COMPANY OF HICKORY, NC, INC. 2016 form 5500 responses
2016-04-01Type of plan entitySingle employer plan
2016-04-01Submission has been amendedNo
2016-04-01This submission is the final filingNo
2016-04-01This return/report is a short plan year return/report (less than 12 months)No
2016-04-01Plan is a collectively bargained planNo
2016-04-01Plan funding arrangement – InsuranceYes
2016-04-01Plan funding arrangement – General assets of the sponsorYes
2016-04-01Plan benefit arrangement – InsuranceYes
2016-04-01Plan benefit arrangement – General assets of the sponsorYes
2015: PEPSI-COLA BOTTLING COMPANY OF HICKORY, NC, INC. 2015 form 5500 responses
2015-04-01Type of plan entitySingle employer plan
2015-04-01Submission has been amendedNo
2015-04-01This submission is the final filingNo
2015-04-01This return/report is a short plan year return/report (less than 12 months)No
2015-04-01Plan is a collectively bargained planNo
2015-04-01Plan funding arrangement – InsuranceYes
2015-04-01Plan benefit arrangement – InsuranceYes
2014: PEPSI-COLA BOTTLING COMPANY OF HICKORY, NC, INC. 2014 form 5500 responses
2014-04-01Type of plan entitySingle employer plan
2014-04-01Submission has been amendedNo
2014-04-01This submission is the final filingNo
2014-04-01This return/report is a short plan year return/report (less than 12 months)No
2014-04-01Plan is a collectively bargained planNo
2014-04-01Plan funding arrangement – InsuranceYes
2014-04-01Plan benefit arrangement – InsuranceYes
2013: PEPSI-COLA BOTTLING COMPANY OF HICKORY, NC, INC. 2013 form 5500 responses
2013-04-01Type of plan entitySingle employer plan
2013-04-01Submission has been amendedNo
2013-04-01This submission is the final filingNo
2013-04-01This return/report is a short plan year return/report (less than 12 months)No
2013-04-01Plan is a collectively bargained planNo
2013-04-01Plan funding arrangement – InsuranceYes
2013-04-01Plan benefit arrangement – InsuranceYes
2012: PEPSI-COLA BOTTLING COMPANY OF HICKORY, NC, INC. 2012 form 5500 responses
2012-04-01Type of plan entitySingle employer plan
2012-04-01Submission has been amendedNo
2012-04-01This submission is the final filingNo
2012-04-01This return/report is a short plan year return/report (less than 12 months)No
2012-04-01Plan is a collectively bargained planNo
2012-04-01Plan funding arrangement – InsuranceYes
2012-04-01Plan benefit arrangement – InsuranceYes
2011: PEPSI-COLA BOTTLING COMPANY OF HICKORY, NC, INC. 2011 form 5500 responses
2011-04-01Type of plan entitySingle employer plan
2011-04-01Submission has been amendedNo
2011-04-01This submission is the final filingNo
2011-04-01This return/report is a short plan year return/report (less than 12 months)No
2011-04-01Plan is a collectively bargained planNo
2011-04-01Plan funding arrangement – InsuranceYes
2011-04-01Plan benefit arrangement – InsuranceYes
2009: PEPSI-COLA BOTTLING COMPANY OF HICKORY, NC, INC. 2009 form 5500 responses
2009-04-01Type of plan entitySingle employer plan
2009-04-01Submission has been amendedNo
2009-04-01This submission is the final filingNo
2009-04-01This return/report is a short plan year return/report (less than 12 months)No
2009-04-01Plan is a collectively bargained planNo
2009-04-01Plan funding arrangement – InsuranceYes
2009-04-01Plan benefit arrangement – InsuranceYes
2008: PEPSI-COLA BOTTLING COMPANY OF HICKORY, NC, INC. 2008 form 5500 responses
2008-05-01Type of plan entitySingle employer plan
2008-05-01Submission has been amendedYes
2008-05-01This submission is the final filingNo
2008-05-01This return/report is a short plan year return/report (less than 12 months)Yes
2008-05-01Plan is a collectively bargained planNo
2008-05-01Plan funding arrangement – InsuranceYes
2008-05-01Plan benefit arrangement – InsuranceYes

Insurance Providers Used on plan

BLUECROSS BLUESHIELD OF NORTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 54631 )
Policy contract number14161345-1001
Policy instance 2
Insurance contract or identification number14161345-1001
Number of Individuals Covered193
Insurance policy start date2022-04-01
Insurance policy end date2023-03-31
Total amount of commissions paid to insurance brokerUSD $2,626
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $26,202
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,626
Amount paid for insurance broker fees0
Insurance broker organization code?3
AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 )
Policy contract number27602
Policy instance 1
Insurance contract or identification number27602
Number of Individuals Covered133
Insurance policy start date2022-04-01
Insurance policy end date2023-03-31
Total amount of commissions paid to insurance brokerUSD $6,737
Total amount of fees paid to insurance companyUSD $0
Life Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENT, CRITICAL ILLNESS
Welfare Benefit Premiums Paid to CarrierUSD $88,077
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,968
Amount paid for insurance broker fees0
Insurance broker organization code?3
USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )
Policy contract number50020164
Policy instance 3
Insurance contract or identification number50020164
Number of Individuals Covered328
Insurance policy start date2022-04-01
Insurance policy end date2023-03-31
Total amount of commissions paid to insurance brokerUSD $42,518
Total amount of fees paid to insurance companyUSD $2,900
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $197,275
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $29,591
Amount paid for insurance broker fees2900
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
Insurance broker organization code?3
BLUECROSS BLUESHIELD OF NORTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 54631 )
Policy contract number14161345-1001
Policy instance 2
Insurance contract or identification number14161345-1001
Number of Individuals Covered303
Insurance policy start date2021-04-01
Insurance policy end date2022-03-31
Total amount of commissions paid to insurance brokerUSD $1,710
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $25,514
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,710
Amount paid for insurance broker fees0
Insurance broker organization code?3
USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )
Policy contract number50020164
Policy instance 3
Insurance contract or identification number50020164
Number of Individuals Covered295
Insurance policy start date2021-04-01
Insurance policy end date2022-03-31
Total amount of commissions paid to insurance brokerUSD $38,823
Total amount of fees paid to insurance companyUSD $3,610
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $180,049
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $27,007
Amount paid for insurance broker fees3610
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
Insurance broker organization code?3
AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 )
Policy contract number27602
Policy instance 1
Insurance contract or identification number27602
Number of Individuals Covered138
Insurance policy start date2021-04-01
Insurance policy end date2022-03-31
Total amount of commissions paid to insurance brokerUSD $7,105
Total amount of fees paid to insurance companyUSD $0
Life Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENT, CRITICAL ILLNESS
Welfare Benefit Premiums Paid to CarrierUSD $94,391
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,252
Amount paid for insurance broker fees0
Insurance broker organization code?3
BLUECROSS BLUESHIELD OF NORTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 54631 )
Policy contract number14161345-1001
Policy instance 2
Insurance contract or identification number14161345-1001
Insurance policy start date2020-04-01
Insurance policy end date2021-03-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )
Policy contract number50020164
Policy instance 3
Insurance contract or identification number50020164
Number of Individuals Covered298
Insurance policy start date2020-04-01
Insurance policy end date2021-03-31
Total amount of commissions paid to insurance brokerUSD $39,502
Total amount of fees paid to insurance companyUSD $24
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $182,666
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $27,452
Amount paid for insurance broker fees24
Additional information about fees paid to insurance brokerFEES/ADDITIONAL COMPENSATION
Insurance broker organization code?3
AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 )
Policy contract number27602
Policy instance 1
Insurance contract or identification number27602
Number of Individuals Covered151
Insurance policy start date2020-04-01
Insurance policy end date2021-03-31
Total amount of commissions paid to insurance brokerUSD $8,521
Total amount of fees paid to insurance companyUSD $56
Life Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENT, CRITICAL ILLNESS
Welfare Benefit Premiums Paid to CarrierUSD $99,839
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6,075
Amount paid for insurance broker fees0
Insurance broker organization code?3
Additional information about fees paid to insurance brokerSUPPLEMENTAL COMPENSATION
USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )
Policy contract number50020164
Policy instance 3
Insurance contract or identification number50020164
Number of Individuals Covered302
Insurance policy start date2019-04-01
Insurance policy end date2020-03-31
Total amount of commissions paid to insurance brokerUSD $38,905
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $180,370
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $27,056
Amount paid for insurance broker fees0
Insurance broker organization code?3
BLUECROSS BLUESHIELD OF NORTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 54631 )
Policy contract numberV09972
Policy instance 2
Insurance contract or identification numberV09972
Number of Individuals Covered318
Insurance policy start date2019-04-01
Insurance policy end date2020-03-31
Total amount of commissions paid to insurance brokerUSD $2,555
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $25,624
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,555
Amount paid for insurance broker fees0
Insurance broker organization code?3
AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 )
Policy contract number27602
Policy instance 1
Insurance contract or identification number27602
Number of Individuals Covered151
Insurance policy start date2019-04-01
Insurance policy end date2020-03-31
Total amount of commissions paid to insurance brokerUSD $9,285
Total amount of fees paid to insurance companyUSD $0
Life Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENT, CRITICAL ILLNESS
Welfare Benefit Premiums Paid to CarrierUSD $103,096
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6,605
Amount paid for insurance broker fees0
Insurance broker organization code?3
USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )
Policy contract number50020164
Policy instance 3
Insurance contract or identification number50020164
Number of Individuals Covered299
Insurance policy start date2018-04-01
Insurance policy end date2019-03-31
Total amount of commissions paid to insurance brokerUSD $38,146
Total amount of fees paid to insurance companyUSD $3,672
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $89,003
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $26,518
Amount paid for insurance broker fees3672
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
Insurance broker organization code?3
BLUECROSS BLUESHIELD OF NORTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 54631 )
Policy contract numberV09972
Policy instance 2
Insurance contract or identification numberV09972
Number of Individuals Covered294
Insurance policy start date2018-04-01
Insurance policy end date2019-03-31
Total amount of commissions paid to insurance brokerUSD $2,395
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $23,945
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,395
Amount paid for insurance broker fees0
Insurance broker organization code?3
AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 )
Policy contract number27602
Policy instance 1
Insurance contract or identification number27602
Number of Individuals Covered156
Insurance policy start date2018-04-01
Insurance policy end date2019-03-31
Total amount of commissions paid to insurance brokerUSD $8,725
Total amount of fees paid to insurance companyUSD $0
Life Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENT, CRITICAL ILLNESS
Welfare Benefit Premiums Paid to CarrierUSD $125,798
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6,361
Amount paid for insurance broker fees0
Insurance broker organization code?3
AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 )
Policy contract number27602
Policy instance 1
Insurance contract or identification number27602
Number of Individuals Covered162
Insurance policy start date2017-04-01
Insurance policy end date2018-03-31
Total amount of commissions paid to insurance brokerUSD $17,448
Total amount of fees paid to insurance companyUSD $0
Life Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENT, CRITICAL ILLNESS
Welfare Benefit Premiums Paid to CarrierUSD $107,403
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $10,957
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameUSI INSURANCE SERVICES NATIONAL INC
USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )
Policy contract number50020164
Policy instance 3
Insurance contract or identification number50020164
Number of Individuals Covered299
Insurance policy start date2017-04-01
Insurance policy end date2018-03-31
Total amount of commissions paid to insurance brokerUSD $36,687
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $170,645
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $25,597
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameMOSIAC GROUP SERVICES
BLUECROSS BLUESHIELD OF NORTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 54631 )
Policy contract numberV09972
Policy instance 2
Insurance contract or identification numberV09972
Number of Individuals Covered295
Insurance policy start date2017-04-01
Insurance policy end date2018-03-31
Total amount of commissions paid to insurance brokerUSD $2,359
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $23,606
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $2,359
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameSCOTT C ANDERSON
AMERICAN GENERAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60488 )
Policy contract numberD96M47
Policy instance 4
Insurance contract or identification numberD96M47
Number of Individuals Covered110
Insurance policy start date2015-04-01
Insurance policy end date2016-03-31
Total amount of commissions paid to insurance brokerUSD $30,952
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 providedVOLUNTARY BENEFITS
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $59,172
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $16,755
Insurance broker organization code?3
Insurance broker nameMOSAIC GROUP SERVICES, LLC
USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )
Policy contract number50020164
Policy instance 3
Insurance contract or identification number50020164
Number of Individuals Covered297
Insurance policy start date2015-04-01
Insurance policy end date2016-03-31
Total amount of commissions paid to insurance brokerUSD $38,068
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
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 $175,054
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $26,258
Insurance broker organization code?3
Insurance broker nameMOSAIC GROUP SERVICES
RENAISSANCE LIFE & HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61700 )
Policy contract number7496
Policy instance 2
Insurance contract or identification number7496
Number of Individuals Covered597
Insurance policy start date2015-04-01
Insurance policy end date2016-03-31
Total amount of commissions paid to insurance brokerUSD $16,986
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?Yes
Commission paid to Insurance BrokerUSD $16,986
Insurance broker organization code?3
Insurance broker nameWELLS FARGO INSURANCE SERVICES
BLUECROSS BLUESHIELD OF NORTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 54631 )
Policy contract number9972/V9972
Policy instance 1
Insurance contract or identification number9972/V9972
Number of Individuals Covered524
Insurance policy start date2015-04-01
Insurance policy end date2016-03-31
Total amount of commissions paid to insurance brokerUSD $72,724
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 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 $1,903,566
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $72,724
Insurance broker organization code?3
Insurance broker nameSCOTT C ANDERSON
PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )
Policy contract number8708908
Policy instance 4
Insurance contract or identification number8708908
Number of Individuals Covered107
Insurance policy start date2014-04-01
Insurance policy end date2015-03-31
Total amount of commissions paid to insurance brokerUSD $1,052
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 providedVOLUNTARY BENEFITS
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $31,677
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $766
Insurance broker organization code?3
Insurance broker nameWACHOVIA INSURANCE SERVICES
BLUECROSS BLUESHIELD OF NORTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 54631 )
Policy contract number9972/V9972
Policy instance 2
Insurance contract or identification number9972/V9972
Number of Individuals Covered505
Insurance policy start date2014-04-01
Insurance policy end date2015-03-31
Total amount of commissions paid to insurance brokerUSD $77,349
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 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 $2,063,390
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $77,046
Insurance broker organization code?3
Insurance broker nameWELLS FARGO INSURANCE SERVICES
USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )
Policy contract number50020164
Policy instance 1
Insurance contract or identification number50020164
Number of Individuals Covered283
Insurance policy start date2014-04-01
Insurance policy end date2015-03-31
Total amount of commissions paid to insurance brokerUSD $37,129
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
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 $170,237
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $25,597
Insurance broker organization code?3
Insurance broker nameMOSAIC GROUP SERVICES
RENAISSANCE LIFE & HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61700 )
Policy contract number7496
Policy instance 3
Insurance contract or identification number7496
Number of Individuals Covered582
Insurance policy start date2014-04-01
Insurance policy end date2015-03-31
Total amount of commissions paid to insurance brokerUSD $25,789
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?Yes
Commission paid to Insurance BrokerUSD $16,237
Insurance broker organization code?3
Insurance broker nameIBSI HOLDINGS, INC.
BLUECROSS BLUESHIELD OF NORTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 54631 )
Policy contract number9972
Policy instance 2
Insurance contract or identification number9972
Number of Individuals Covered526
Insurance policy start date2013-04-01
Insurance policy end date2014-03-31
Total amount of commissions paid to insurance brokerUSD $77,299
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 $1,841,239
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $77,299
Insurance broker organization code?3
Insurance broker nameWELLS FARGO INSURANCE SERVICES
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number36892/95705
Policy instance 1
Insurance contract or identification number36892/95705
Number of Individuals Covered288
Insurance policy start date2013-04-01
Insurance policy end date2014-03-31
Total amount of commissions paid to insurance brokerUSD $21,672
Total amount of fees paid to insurance companyUSD $1,958
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 BenefitYes
Long Term Disability Insurance Welfare BenefitYes
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 $149,066
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $21,672
Amount paid for insurance broker fees1958
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
Insurance broker organization code?3
Insurance broker nameWELLS FARGO INSURANCE SERVICES
RENAISSANCE LIFE & HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61700 )
Policy contract number7496
Policy instance 3
Insurance contract or identification number7496
Number of Individuals Covered610
Insurance policy start date2013-04-01
Insurance policy end date2014-03-31
Total amount of commissions paid to insurance brokerUSD $26,320
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?Yes
Commission paid to Insurance BrokerUSD $16,571
Insurance broker organization code?3
Insurance broker nameIBSI HOLDINGS, INC.
PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )
Policy contract number8708908
Policy instance 4
Insurance contract or identification number8708908
Number of Individuals Covered115
Insurance policy start date2013-04-01
Insurance policy end date2014-03-31
Total amount of commissions paid to insurance brokerUSD $1,192
Total amount of fees paid to insurance companyUSD $12
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 providedVOLUNTARY BENEFITS
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 $36,723
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $783
Amount paid for insurance broker fees12
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
Insurance broker organization code?3
Insurance broker nameWELLS FARGO INSURANCE SERVICES
BLUECROSS BLUESHIELD OF NORTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 54631 )
Policy contract number9972
Policy instance 2
Insurance contract or identification number9972
Number of Individuals Covered535
Insurance policy start date2012-04-01
Insurance policy end date2013-03-31
Total amount of commissions paid to insurance brokerUSD $80,651
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 $1,869,747
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $80,651
Insurance broker organization code?3
Insurance broker nameWELLS FARGO INSURANCE SERVICES
RENAISSANCE LIFE & HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61700 )
Policy contract number7496
Policy instance 3
Insurance contract or identification number7496
Number of Individuals Covered637
Insurance policy start date2012-04-01
Insurance policy end date2013-03-31
Total amount of commissions paid to insurance brokerUSD $26,368
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?Yes
Commission paid to Insurance BrokerUSD $16,601
Insurance broker organization code?3
Insurance broker nameIBSI HOLDINGS, INC.
PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )
Policy contract number8708908
Policy instance 4
Insurance contract or identification number8708908
Number of Individuals Covered122
Insurance policy start date2012-01-01
Insurance policy end date2012-12-31
Total amount of commissions paid to insurance brokerUSD $1,860
Total amount of fees paid to insurance companyUSD $1
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 providedVOLUNTARY BENEFITS
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 $38,669
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $945
Amount paid for insurance broker fees1
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
Insurance broker organization code?3
Insurance broker nameWELLS FARGO INSURANCE SERVICES
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number36892/95705
Policy instance 1
Insurance contract or identification number36892/95705
Number of Individuals Covered293
Insurance policy start date2012-04-01
Insurance policy end date2013-03-31
Total amount of commissions paid to insurance brokerUSD $22,239
Total amount of fees paid to insurance companyUSD $1,387
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 BenefitYes
Long Term Disability Insurance Welfare BenefitYes
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 $158,844
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $22,239
Amount paid for insurance broker fees1387
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
Insurance broker organization code?3
Insurance broker nameWELLS FARGO INSURANCE SERVICES
BLUECROSS BLUESHIELD OF NORTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 54631 )
Policy contract number9972
Policy instance 1
Insurance contract or identification number9972
Number of Individuals Covered565
Insurance policy start date2011-04-01
Insurance policy end date2012-03-31
Total amount of commissions paid to insurance brokerUSD $83,756
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 $1,884,174
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
RENAISSANCE LIFE & HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61700 )
Policy contract number7496
Policy instance 2
Insurance contract or identification number7496
Number of Individuals Covered681
Insurance policy start date2011-04-01
Insurance policy end date2012-03-31
Total amount of commissions paid to insurance brokerUSD $25,810
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?Yes
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number95705/36892
Policy instance 3
Insurance contract or identification number95705/36892
Number of Individuals Covered303
Insurance policy start date2011-04-01
Insurance policy end date2012-03-31
Total amount of commissions paid to insurance brokerUSD $23,468
Total amount of fees paid to insurance companyUSD $1,826
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 BenefitYes
Long Term Disability Insurance Welfare BenefitYes
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 $156,459
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
RENAISSANCE LIFE & HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61700 )
Policy contract numberRD007496
Policy instance 2
Insurance contract or identification numberRD007496
Number of Individuals Covered686
Insurance policy start date2010-04-01
Insurance policy end date2011-03-31
Total amount of commissions paid to insurance brokerUSD $24,112
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 $15,181
Insurance broker organization code?3
Insurance broker nameIBSI HOLDINGS
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number036892
Policy instance 3
Insurance contract or identification number036892
Number of Individuals Covered317
Insurance policy start date2010-01-01
Insurance policy end date2010-12-31
Total amount of commissions paid to insurance brokerUSD $11,561
Total amount of fees paid to insurance companyUSD $1,687
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 BenefitYes
Long Term Disability Insurance Welfare BenefitYes
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 $80,487
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $11,561
Amount paid for insurance broker fees1687
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
Insurance broker organization code?3
Insurance broker nameWELLS FARGO INSURANCE SERVICES
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number036892
Policy instance 4
Insurance contract or identification number036892
Number of Individuals Covered317
Insurance policy start date2011-01-01
Insurance policy end date2011-03-31
Total amount of commissions paid to insurance brokerUSD $3,861
Total amount of fees paid to insurance companyUSD $556
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 BenefitYes
Long Term Disability Insurance Welfare BenefitYes
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 $25,742
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,861
Amount paid for insurance broker fees556
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
Insurance broker organization code?3
Insurance broker nameWELLS FARGO INSURANCE SERVICES
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number095705
Policy instance 5
Insurance contract or identification number095705
Number of Individuals Covered165
Insurance policy start date2010-04-01
Insurance policy end date2011-03-31
Total amount of commissions paid to insurance brokerUSD $7,835
Total amount of fees paid to insurance companyUSD $1,234
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 $49,563
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $7,835
Amount paid for insurance broker fees1234
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
Insurance broker organization code?3
Insurance broker nameWELLS FARGO INSURANCE SERVICES
BLUECROSS BLUESHIELD OF NORTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 54631 )
Policy contract number009972
Policy instance 1
Insurance contract or identification number009972
Number of Individuals Covered572
Insurance policy start date2010-04-01
Insurance policy end date2011-03-31
Total amount of commissions paid to insurance brokerUSD $98,798
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 $1,979,002
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $98,798
Insurance broker organization code?3
Insurance broker nameWELLS FARGO INSURANCE SERVICES

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