ADAMS ELECTRIC COMPANY has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan ADAMS ELECTRIC COMPANY, INC EMPLOYEE GROUP HEALTH AND WELFARE BENEFIT PLAN
401k plan membership statisitcs for ADAMS ELECTRIC COMPANY, INC EMPLOYEE GROUP HEALTH AND WELFARE BENEFIT PLAN
| 2023: ADAMS ELECTRIC COMPANY, INC EMPLOYEE GROUP HEALTH AND WELFARE BENEFIT PLAN 2023 form 5500 responses |
|---|
| 2023-04-01 | Type of plan entity | Single employer plan |
| 2023-04-01 | Submission has been amended | No |
| 2023-04-01 | This submission is the final filing | No |
| 2023-04-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2023-04-01 | Plan is a collectively bargained plan | No |
| 2023-04-01 | Plan funding arrangement – Insurance | Yes |
| 2023-04-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2023-04-01 | Plan benefit arrangement – Insurance | Yes |
| 2023-04-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2022: ADAMS ELECTRIC COMPANY, INC EMPLOYEE GROUP HEALTH AND WELFARE BENEFIT PLAN 2022 form 5500 responses |
|---|
| 2022-04-01 | Type of plan entity | Single employer plan |
| 2022-04-01 | Submission has been amended | No |
| 2022-04-01 | This submission is the final filing | No |
| 2022-04-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2022-04-01 | Plan is a collectively bargained plan | No |
| 2022-04-01 | Plan funding arrangement – Insurance | Yes |
| 2022-04-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2022-04-01 | Plan benefit arrangement – Insurance | Yes |
| 2022-04-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2021: ADAMS ELECTRIC COMPANY, INC EMPLOYEE GROUP HEALTH AND WELFARE BENEFIT PLAN 2021 form 5500 responses |
|---|
| 2021-04-01 | Type of plan entity | Single employer plan |
| 2021-04-01 | Submission has been amended | No |
| 2021-04-01 | This submission is the final filing | No |
| 2021-04-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2021-04-01 | Plan is a collectively bargained plan | No |
| 2021-04-01 | Plan funding arrangement – Insurance | Yes |
| 2021-04-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2021-04-01 | Plan benefit arrangement – Insurance | Yes |
| 2021-04-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2020: ADAMS ELECTRIC COMPANY, INC EMPLOYEE GROUP HEALTH AND WELFARE BENEFIT PLAN 2020 form 5500 responses |
|---|
| 2020-04-01 | Type of plan entity | Single employer plan |
| 2020-04-01 | Submission has been amended | No |
| 2020-04-01 | This submission is the final filing | No |
| 2020-04-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2020-04-01 | Plan is a collectively bargained plan | No |
| 2020-04-01 | Plan funding arrangement – Insurance | Yes |
| 2020-04-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2020-04-01 | Plan benefit arrangement – Insurance | Yes |
| 2020-04-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2019: ADAMS ELECTRIC COMPANY, INC EMPLOYEE GROUP HEALTH AND WELFARE BENEFIT PLAN 2019 form 5500 responses |
|---|
| 2019-04-01 | Type of plan entity | Single employer plan |
| 2019-04-01 | Submission has been amended | No |
| 2019-04-01 | This submission is the final filing | No |
| 2019-04-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2019-04-01 | Plan is a collectively bargained plan | No |
| 2019-04-01 | Plan funding arrangement – Insurance | Yes |
| 2019-04-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2019-04-01 | Plan benefit arrangement – Insurance | Yes |
| 2019-04-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2018: ADAMS ELECTRIC COMPANY, INC EMPLOYEE GROUP HEALTH AND WELFARE BENEFIT PLAN 2018 form 5500 responses |
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| 2018-04-01 | Type of plan entity | Single employer plan |
| 2018-04-01 | Submission has been amended | No |
| 2018-04-01 | This submission is the final filing | No |
| 2018-04-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2018-04-01 | Plan is a collectively bargained plan | No |
| 2018-04-01 | Plan funding arrangement – Insurance | Yes |
| 2018-04-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2018-04-01 | Plan benefit arrangement – Insurance | Yes |
| 2018-04-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2017: ADAMS ELECTRIC COMPANY, INC EMPLOYEE GROUP HEALTH AND WELFARE BENEFIT PLAN 2017 form 5500 responses |
|---|
| 2017-04-01 | Type of plan entity | Single employer plan |
| 2017-04-01 | Plan funding arrangement – Insurance | Yes |
| 2017-04-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2017-04-01 | Plan benefit arrangement – Insurance | Yes |
| 2017-04-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2016: ADAMS ELECTRIC COMPANY, INC EMPLOYEE GROUP HEALTH AND WELFARE BENEFIT PLAN 2016 form 5500 responses |
|---|
| 2016-04-01 | Type of plan entity | Single employer plan |
| 2016-04-01 | Plan funding arrangement – Insurance | Yes |
| 2016-04-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2016-04-01 | Plan benefit arrangement – Insurance | Yes |
| 2016-04-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2015: ADAMS ELECTRIC COMPANY, INC EMPLOYEE GROUP HEALTH AND WELFARE BENEFIT PLAN 2015 form 5500 responses |
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| 2015-04-01 | Type of plan entity | Single employer plan |
| 2015-04-01 | Plan funding arrangement – Insurance | Yes |
| 2015-04-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2015-04-01 | Plan benefit arrangement – Insurance | Yes |
| 2015-04-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2014: ADAMS ELECTRIC COMPANY, INC EMPLOYEE GROUP HEALTH AND WELFARE BENEFIT PLAN 2014 form 5500 responses |
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| 2014-04-01 | Type of plan entity | Single employer plan |
| 2014-04-01 | Plan funding arrangement – Insurance | Yes |
| 2014-04-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2014-04-01 | Plan benefit arrangement – Insurance | Yes |
| 2014-04-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2013: ADAMS ELECTRIC COMPANY, INC EMPLOYEE GROUP HEALTH AND WELFARE BENEFIT PLAN 2013 form 5500 responses |
|---|
| 2013-04-01 | Type of plan entity | Single employer plan |
| 2013-04-01 | Plan funding arrangement – Insurance | Yes |
| 2013-04-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2013-04-01 | Plan benefit arrangement – Insurance | Yes |
| 2013-04-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2012: ADAMS ELECTRIC COMPANY, INC EMPLOYEE GROUP HEALTH AND WELFARE BENEFIT PLAN 2012 form 5500 responses |
|---|
| 2012-04-01 | Type of plan entity | Single employer plan |
| 2012-04-01 | Plan funding arrangement – Insurance | Yes |
| 2012-04-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2012-04-01 | Plan benefit arrangement – Insurance | Yes |
| 2012-04-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2011: ADAMS ELECTRIC COMPANY, INC EMPLOYEE GROUP HEALTH AND WELFARE BENEFIT PLAN 2011 form 5500 responses |
|---|
| 2011-04-01 | Type of plan entity | Single employer plan |
| 2011-04-01 | Plan funding arrangement – Insurance | Yes |
| 2011-04-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2011-04-01 | Plan benefit arrangement – Insurance | Yes |
| 2011-04-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2009: ADAMS ELECTRIC COMPANY, INC EMPLOYEE GROUP HEALTH AND WELFARE BENEFIT PLAN 2009 form 5500 responses |
|---|
| 2009-04-01 | Type of plan entity | Single employer plan |
| 2009-04-01 | This submission is the final filing | No |
| 2009-04-01 | Plan funding arrangement – Insurance | Yes |
| 2009-04-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2009-04-01 | Plan benefit arrangement – Insurance | Yes |
| 2009-04-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 34237 |
| Policy instance | 1 |
| Insurance contract or identification number | 34237 | | Number of Individuals Covered | 371 | | Insurance policy start date | 2023-04-01 | | Insurance policy end date | 2024-03-31 | | Total amount of commissions paid to insurance broker | USD $53,614 | | Total amount of fees paid to insurance company | USD $3,762 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | AD&D, ACCIDENT, CRITICAL ILLNESS | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $330,672 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 34237 |
| Policy instance | 1 |
| Insurance contract or identification number | 34237 | | Number of Individuals Covered | 340 | | Insurance policy start date | 2022-04-01 | | Insurance policy end date | 2023-03-31 | | Total amount of commissions paid to insurance broker | USD $85,997 | | Total amount of fees paid to insurance company | USD $4,434 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | AD&D, ACCIDENT, CRITICAL ILLNESS | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $360,103 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $85,997 | | Amount paid for insurance broker fees | 4434 | | Additional information about fees paid to insurance broker | FEES PAID | | Insurance broker organization code? | 3 |
|
| COMMUNITY EYE CARE (National Association of Insurance Commissioners NAIC id number: 52429 ) |
| Policy contract number | TPO35012 |
| Policy instance | 8 |
| Insurance contract or identification number | TPO35012 | | Number of Individuals Covered | 359 | | Insurance policy start date | 2021-04-01 | | Insurance policy end date | 2022-03-31 | | Total amount of commissions paid to insurance broker | USD $3,162 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $31,622 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,162 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLTD0AWZQ |
| Policy instance | 1 |
| Insurance contract or identification number | GLTD0AWZQ | | Number of Individuals Covered | 96 | | Insurance policy start date | 2021-04-01 | | Insurance policy end date | 2022-03-31 | | Total amount of commissions paid to insurance broker | USD $4,026 | | Total amount of fees paid to insurance company | USD $1,094 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $26,842 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,026 | | Amount paid for insurance broker fees | 1094 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG0AWZQ |
| Policy instance | 2 |
| Insurance contract or identification number | GLUG0AWZQ | | Number of Individuals Covered | 333 | | Insurance policy start date | 2021-04-01 | | Insurance policy end date | 2022-03-31 | | Total amount of commissions paid to insurance broker | USD $2,585 | | Total amount of fees paid to insurance company | USD $704 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | AD&D | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $17,236 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,585 | | Amount paid for insurance broker fees | 704 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUDE0AWZQ |
| Policy instance | 3 |
| Insurance contract or identification number | GUDE0AWZQ | | Number of Individuals Covered | 78 | | Insurance policy start date | 2021-04-01 | | Insurance policy end date | 2022-03-31 | | Total amount of commissions paid to insurance broker | USD $2,684 | | Total amount of fees paid to insurance company | USD $2,216 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | CRITICAL ILLNESS | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $17,895 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,684 | | Amount paid for insurance broker fees | 704 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUDH0AWZQ |
| Policy instance | 4 |
| Insurance contract or identification number | GUDH0AWZQ | | Number of Individuals Covered | 121 | | Insurance policy start date | 2021-04-01 | | Insurance policy end date | 2022-03-31 | | Total amount of commissions paid to insurance broker | USD $4,371 | | Total amount of fees paid to insurance company | USD $2,697 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | 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 Carrier | USD $29,137 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,371 | | Amount paid for insurance broker fees | 1197 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUG 0AWZQ |
| Policy instance | 5 |
| Insurance contract or identification number | GUG 0AWZQ | | Number of Individuals Covered | 218 | | Insurance policy start date | 2021-04-01 | | Insurance policy end date | 2022-03-31 | | Total amount of commissions paid to insurance broker | USD $12,520 | | Total amount of fees paid to insurance company | USD $3,443 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $83,466 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $12,520 | | Amount paid for insurance broker fees | 3443 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUPR0AWZQ |
| Policy instance | 6 |
| Insurance contract or identification number | GUPR0AWZQ | | Number of Individuals Covered | 81 | | Insurance policy start date | 2021-04-01 | | Insurance policy end date | 2022-03-31 | | Total amount of commissions paid to insurance broker | USD $3,713 | | Total amount of fees paid to insurance company | USD $1,024 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $24,756 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,713 | | Amount paid for insurance broker fees | 1024 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GVTL0AWZQ |
| Policy instance | 7 |
| Insurance contract or identification number | GVTL0AWZQ | | Number of Individuals Covered | 149 | | Insurance policy start date | 2021-04-01 | | Insurance policy end date | 2022-03-31 | | Total amount of commissions paid to insurance broker | USD $9,441 | | Total amount of fees paid to insurance company | USD $4,384 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | AD&D | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $62,940 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $9,441 | | Amount paid for insurance broker fees | 2548 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG0AWZQ |
| Policy instance | 2 |
| Insurance contract or identification number | GLUG0AWZQ | | Number of Individuals Covered | 314 | | Insurance policy start date | 2020-08-01 | | Insurance policy end date | 2021-03-31 | | Total amount of commissions paid to insurance broker | USD $1,731 | | Total amount of fees paid to insurance company | USD $389 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | AD&D | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $11,538 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUDE0AWZQ |
| Policy instance | 3 |
| Insurance contract or identification number | GUDE0AWZQ | | Number of Individuals Covered | 75 | | Insurance policy start date | 2020-08-01 | | Insurance policy end date | 2021-03-31 | | Total amount of commissions paid to insurance broker | USD $1,471 | | Total amount of fees paid to insurance company | USD $1,294 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | CRITICAL ILLNESS | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $9,806 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| COMMUNITY EYE CARE (National Association of Insurance Commissioners NAIC id number: 52429 ) |
| Policy contract number | TPO35012 |
| Policy instance | 8 |
| Insurance contract or identification number | TPO35012 | | Number of Individuals Covered | 333 | | Insurance policy start date | 2020-04-01 | | Insurance policy end date | 2021-03-31 | | Total amount of commissions paid to insurance broker | USD $3,202 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $32,025 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GVTL0AWZQ |
| Policy instance | 7 |
| Insurance contract or identification number | GVTL0AWZQ | | Number of Individuals Covered | 146 | | Insurance policy start date | 2020-08-01 | | Insurance policy end date | 2021-03-31 | | Total amount of commissions paid to insurance broker | USD $5,973 | | Total amount of fees paid to insurance company | USD $2,561 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | AD&D | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $39,823 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUPR0AWZQ |
| Policy instance | 6 |
| Insurance contract or identification number | GUPR0AWZQ | | Number of Individuals Covered | 78 | | Insurance policy start date | 2020-08-01 | | Insurance policy end date | 2021-03-31 | | Total amount of commissions paid to insurance broker | USD $2,626 | | Total amount of fees paid to insurance company | USD $599 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $17,509 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUG 0AWZQ |
| Policy instance | 5 |
| Insurance contract or identification number | GUG 0AWZQ | | Number of Individuals Covered | 212 | | Insurance policy start date | 2020-08-01 | | Insurance policy end date | 2021-03-31 | | Total amount of commissions paid to insurance broker | USD $8,487 | | Total amount of fees paid to insurance company | USD $1,880 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $56,577 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLTD0AWZQ |
| Policy instance | 1 |
| Insurance contract or identification number | GLTD0AWZQ | | Number of Individuals Covered | 94 | | Insurance policy start date | 2020-08-01 | | Insurance policy end date | 2021-03-31 | | Total amount of commissions paid to insurance broker | USD $2,618 | | Total amount of fees paid to insurance company | USD $571 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $17,453 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUDH0AWZQ |
| Policy instance | 4 |
| Insurance contract or identification number | GUDH0AWZQ | | Number of Individuals Covered | 120 | | Insurance policy start date | 2020-08-01 | | Insurance policy end date | 2021-03-31 | | Total amount of commissions paid to insurance broker | USD $2,866 | | Total amount of fees paid to insurance company | USD $1,599 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | 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 Carrier | USD $19,107 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| COMMUNITY EYE CARE (National Association of Insurance Commissioners NAIC id number: 52429 ) |
| Policy contract number | TPO35012 |
| Policy instance | 8 |
| Insurance contract or identification number | TPO35012 | | Number of Individuals Covered | 357 | | Insurance policy start date | 2019-04-01 | | Insurance policy end date | 2020-03-31 | | Total amount of commissions paid to insurance broker | USD $3,542 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $35,416 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GVTL0AWZQ |
| Policy instance | 7 |
| Insurance contract or identification number | GVTL0AWZQ | | Number of Individuals Covered | 162 | | Insurance policy start date | 2019-04-01 | | Insurance policy end date | 2020-03-31 | | Total amount of commissions paid to insurance broker | USD $9,108 | | Total amount of fees paid to insurance company | USD $1,836 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | AD&D | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $60,721 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUPR0AWZQ |
| Policy instance | 6 |
| Insurance contract or identification number | GUPR0AWZQ | | Number of Individuals Covered | 95 | | Insurance policy start date | 2019-04-01 | | Insurance policy end date | 2020-03-31 | | Total amount of commissions paid to insurance broker | USD $3,965 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $26,431 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUDH0AWZQ |
| Policy instance | 4 |
| Insurance contract or identification number | GUDH0AWZQ | | Number of Individuals Covered | 108 | | Insurance policy start date | 2019-04-01 | | Insurance policy end date | 2020-03-31 | | Total amount of commissions paid to insurance broker | USD $3,808 | | Total amount of fees paid to insurance company | USD $1,500 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | 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 Carrier | USD $25,387 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLTD0AWZQ |
| Policy instance | 1 |
| Insurance contract or identification number | GLTD0AWZQ | | Number of Individuals Covered | 90 | | Insurance policy start date | 2019-04-01 | | Insurance policy end date | 2020-03-31 | | Total amount of commissions paid to insurance broker | USD $3,588 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $23,918 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG0AWZQ |
| Policy instance | 2 |
| Insurance contract or identification number | GLUG0AWZQ | | Number of Individuals Covered | 329 | | Insurance policy start date | 2019-04-01 | | Insurance policy end date | 2020-03-31 | | Total amount of commissions paid to insurance broker | USD $2,531 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | AD&D | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $16,871 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUDE0AWZQ |
| Policy instance | 3 |
| Insurance contract or identification number | GUDE0AWZQ | | Number of Individuals Covered | 67 | | Insurance policy start date | 2019-04-01 | | Insurance policy end date | 2020-03-31 | | Total amount of commissions paid to insurance broker | USD $1,815 | | Total amount of fees paid to insurance company | USD $1,512 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | CRITICAL ILLNESS | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $12,101 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUG 0AWZQ |
| Policy instance | 5 |
| Insurance contract or identification number | GUG 0AWZQ | | Number of Individuals Covered | 225 | | Insurance policy start date | 2019-04-01 | | Insurance policy end date | 2020-03-31 | | Total amount of commissions paid to insurance broker | USD $12,486 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $83,240 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLTD0AWZQ |
| Policy instance | 1 |
| Insurance contract or identification number | GLTD0AWZQ | | Number of Individuals Covered | 74 | | Insurance policy start date | 2018-03-01 | | Insurance policy end date | 2019-02-28 | | Total amount of commissions paid to insurance broker | USD $3,108 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $20,720 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| COMMUNITY EYE CARE (National Association of Insurance Commissioners NAIC id number: 52429 ) |
| Policy contract number | TPO35012 |
| Policy instance | 8 |
| Insurance contract or identification number | TPO35012 | | Number of Individuals Covered | 341 | | Insurance policy start date | 2018-04-01 | | Insurance policy end date | 2019-03-31 | | Total amount of commissions paid to insurance broker | USD $3,297 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $32,968 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GVTL0AWZQ |
| Policy instance | 7 |
| Insurance contract or identification number | GVTL0AWZQ | | Number of Individuals Covered | 155 | | Insurance policy start date | 2018-03-01 | | Insurance policy end date | 2019-02-28 | | Total amount of commissions paid to insurance broker | USD $9,047 | | Total amount of fees paid to insurance company | USD $1,683 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | AD&D | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $60,315 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUPR0AWZQ |
| Policy instance | 6 |
| Insurance contract or identification number | GUPR0AWZQ | | Number of Individuals Covered | 101 | | Insurance policy start date | 2018-03-01 | | Insurance policy end date | 2019-02-28 | | Total amount of commissions paid to insurance broker | USD $3,752 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $25,015 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUG 0AWZQ |
| Policy instance | 5 |
| Insurance contract or identification number | GUG 0AWZQ | | Number of Individuals Covered | 221 | | Insurance policy start date | 2018-03-01 | | Insurance policy end date | 2019-02-28 | | Total amount of commissions paid to insurance broker | USD $12,145 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $80,966 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUDH0AWZQ |
| Policy instance | 4 |
| Insurance contract or identification number | GUDH0AWZQ | | Number of Individuals Covered | 75 | | Insurance policy start date | 2018-03-01 | | Insurance policy end date | 2019-02-28 | | Total amount of commissions paid to insurance broker | USD $3,568 | | Total amount of fees paid to insurance company | USD $1,375 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | 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 Carrier | USD $18,216 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUDE0AWZQ |
| Policy instance | 3 |
| Insurance contract or identification number | GUDE0AWZQ | | Number of Individuals Covered | 60 | | Insurance policy start date | 2018-03-01 | | Insurance policy end date | 2019-02-28 | | Total amount of commissions paid to insurance broker | USD $2,124 | | Total amount of fees paid to insurance company | USD $1,386 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | CRITICAL ILLNESS | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $14,161 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG0AWZQ |
| Policy instance | 2 |
| Insurance contract or identification number | GLUG0AWZQ | | Number of Individuals Covered | 308 | | Insurance policy start date | 2018-03-01 | | Insurance policy end date | 2019-02-28 | | Total amount of commissions paid to insurance broker | USD $2,286 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | AD&D | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $15,240 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUDE0AWZQ |
| Policy instance | 7 |
| Insurance contract or identification number | GUDE0AWZQ | | Number of Individuals Covered | 58 | | Insurance policy start date | 2017-04-01 | | Insurance policy end date | 2018-03-31 | | Total amount of commissions paid to insurance broker | USD $313 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | CRITICAL ILLNESS | | Welfare Benefit Premiums Paid to Carrier | USD $2,090 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $313 | | Insurance broker organization code? | 3 | | Insurance broker name | WILLIFORD INS GROUP |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUDH0AWZQ |
| Policy instance | 6 |
| Insurance contract or identification number | GUDH0AWZQ | | Number of Individuals Covered | 60 | | Insurance policy start date | 2017-04-01 | | Insurance policy end date | 2018-03-31 | | Total amount of commissions paid to insurance broker | USD $510 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | ACCIDENT | | Welfare Benefit Premiums Paid to Carrier | USD $2,549 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $510 | | Insurance broker organization code? | 3 | | Insurance broker name | WILLIFORD INS GROUP |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GVTLOAWZQ |
| Policy instance | 5 |
| Insurance contract or identification number | GVTLOAWZQ | | Number of Individuals Covered | 110 | | Insurance policy start date | 2017-04-01 | | Insurance policy end date | 2018-03-31 | | Total amount of commissions paid to insurance broker | USD $7,612 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $50,744 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,612 | | Insurance broker organization code? | 3 | | Insurance broker name | WILLIFORD INS GROUP |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLTDOAWZQ |
| Policy instance | 4 |
| Insurance contract or identification number | GLTDOAWZQ | | Number of Individuals Covered | 158 | | Insurance policy start date | 2017-04-01 | | Insurance policy end date | 2018-03-31 | | Total amount of commissions paid to insurance broker | USD $8,781 | | Total amount of fees paid to insurance company | USD $0 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $58,537 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,781 | | Insurance broker organization code? | 3 | | Insurance broker name | WILLIFORD INS GROUP |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUGOAWZQ |
| Policy instance | 3 |
| Insurance contract or identification number | GUGOAWZQ | | Number of Individuals Covered | 71 | | Insurance policy start date | 2017-04-01 | | Insurance policy end date | 2018-03-31 | | Total amount of commissions paid to insurance broker | USD $2,915 | | Total amount of fees paid to insurance company | USD $0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $19,431 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,915 | | Insurance broker organization code? | 3 | | Insurance broker name | WILLIFORD INS GROUP |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUGOAWZQ |
| Policy instance | 2 |
| Insurance contract or identification number | GLUGOAWZQ | | Number of Individuals Covered | 303 | | Insurance policy start date | 2017-04-01 | | Insurance policy end date | 2018-03-31 | | Total amount of commissions paid to insurance broker | USD $2,011 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACC DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $13,406 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,011 | | Insurance broker organization code? | 3 | | Insurance broker name | WILLIFORD INS GROUP |
|
| BLUECROSS BLUESHIELD OF NORTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 54631 ) |
| Policy contract number | 075879 |
| Policy instance | 1 |
| Insurance contract or identification number | 075879 | | Number of Individuals Covered | 195 | | Insurance policy start date | 2017-04-01 | | Insurance policy end date | 2018-03-31 | | Total amount of commissions paid to insurance broker | USD $36,455 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $36,455 | | Insurance broker organization code? | 3 | | Insurance broker name | WILLIFORD INS GROUP |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLTDOAWZQ |
| Policy instance | 8 |
| Insurance contract or identification number | GLTDOAWZQ | | Number of Individuals Covered | 67 | | Insurance policy start date | 2015-08-01 | | Insurance policy end date | 2016-08-01 | | Total amount of commissions paid to insurance broker | USD $2,593 | | Total amount of fees paid to insurance company | USD $185 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $17,288 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,593 | | Amount paid for insurance broker fees | 185 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | WILLIFORD INS GROUP |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUGOAWZQ |
| Policy instance | 7 |
| Insurance contract or identification number | GUGOAWZQ | | Number of Individuals Covered | 162 | | Insurance policy start date | 2015-08-01 | | Insurance policy end date | 2016-08-01 | | Total amount of commissions paid to insurance broker | USD $7,652 | | Total amount of fees paid to insurance company | USD $593 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $51,016 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,652 | | Amount paid for insurance broker fees | 593 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | WILLIFORD INS GROUP |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUGOAWZQ |
| Policy instance | 6 |
| Insurance contract or identification number | GLUGOAWZQ | | Number of Individuals Covered | 244 | | Insurance policy start date | 2015-08-01 | | Insurance policy end date | 2016-08-01 | | Total amount of commissions paid to insurance broker | USD $2,114 | | Total amount of fees paid to insurance company | USD $168 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACC DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $14,091 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,114 | | Amount paid for insurance broker fees | 168 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | WILLIFORD INS GROUP |
|
| USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 ) |
| Policy contract number | 50018988 |
| Policy instance | 5 |
| Insurance contract or identification number | 50018988 | | Number of Individuals Covered | 115 | | Insurance policy start date | 2015-07-01 | | Insurance policy end date | 2015-08-01 | | Total amount of commissions paid to insurance broker | USD $693 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $2,774 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $416 | | Insurance broker organization code? | 3 | | Insurance broker name | MOSAIC GROUP SERVICES |
|
| USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 ) |
| Policy contract number | 50018988 |
| Policy instance | 4 |
| Insurance contract or identification number | 50018988 | | Number of Individuals Covered | 165 | | Insurance policy start date | 2015-07-01 | | Insurance policy end date | 2015-08-01 | | Total amount of commissions paid to insurance broker | USD $797 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | SHORT TERM DISABILITY | | Welfare Benefit Premiums Paid to Carrier | USD $3,985 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $598 | | Insurance broker organization code? | 3 | | Insurance broker name | MOSAIC GROUP SERVICES |
|
| USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 ) |
| Policy contract number | 50018988 |
| Policy instance | 3 |
| Insurance contract or identification number | 50018988 | | Number of Individuals Covered | 74 | | Insurance policy start date | 2015-07-01 | | Insurance policy end date | 2015-08-01 | | Total amount of commissions paid to insurance broker | USD $347 | | Total amount of fees paid to insurance company | USD $0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,826 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $274 | | Insurance broker organization code? | 3 | | Insurance broker name | MOSAIC GROUP SERVICES |
|
| USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 ) |
| Policy contract number | 50018988 |
| Policy instance | 2 |
| Insurance contract or identification number | 50018988 | | Number of Individuals Covered | 357 | | Insurance policy start date | 2015-07-01 | | Insurance policy end date | 2015-08-01 | | Total amount of commissions paid to insurance broker | USD $480 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACC DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $2,403 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $360 | | Insurance broker organization code? | 3 | | Insurance broker name | MOSAIC GROUP SERVICES |
|
| BLUECROSS BLUESHIELD OF NORTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 54631 ) |
| Policy contract number | 075879 |
| Policy instance | 1 |
| Insurance contract or identification number | 075879 | | Number of Individuals Covered | 181 | | Insurance policy start date | 2015-04-01 | | Insurance policy end date | 2016-03-31 | | Total amount of commissions paid to insurance broker | USD $19,302 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $217,184 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $19,302 | | Insurance broker organization code? | 3 | | Insurance broker name | WILLIFORD INS GROUP |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GVTLOAWZQ |
| Policy instance | 9 |
| Insurance contract or identification number | GVTLOAWZQ | | Number of Individuals Covered | 125 | | Insurance policy start date | 2015-08-01 | | Insurance policy end date | 2016-08-01 | | Total amount of commissions paid to insurance broker | USD $8,143 | | Total amount of fees paid to insurance company | USD $634 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $54,285 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,143 | | Amount paid for insurance broker fees | 634 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | WILLIFORD INS GROUP |
|
| USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 ) |
| Policy contract number | 50018988 |
| Policy instance | 4 |
| Insurance contract or identification number | 50018988 | | Number of Individuals Covered | 162 | | Insurance policy start date | 2014-04-01 | | Insurance policy end date | 2015-03-31 | | Total amount of commissions paid to insurance broker | USD $5,048 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Other welfare benefits provided | SHORT TERM DISABILITY | | Welfare Benefit Premiums Paid to Carrier | USD $25,239 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,786 | | Insurance broker name | MOSAIC GROUP SERVICES |
|
| USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 ) |
| Policy contract number | 50018988 |
| Policy instance | 5 |
| Insurance contract or identification number | 50018988 | | Number of Individuals Covered | 114 | | Insurance policy start date | 2014-04-01 | | Insurance policy end date | 2015-03-31 | | Total amount of commissions paid to insurance broker | USD $5,390 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $21,562 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,234 | | Insurance broker name | MOSAIC GROUP SERVICES |
|
| USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 ) |
| Policy contract number | 50018988 |
| Policy instance | 2 |
| Insurance contract or identification number | 50018988 | | Number of Individuals Covered | 329 | | Insurance policy start date | 2014-04-01 | | Insurance policy end date | 2015-03-31 | | Total amount of commissions paid to insurance broker | USD $2,491 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACC DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $12,454 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,868 | | Insurance broker organization code? | 3 | | Insurance broker name | MOSAIC GROUP SERVICES |
|
| BLUECROSS BLUESHIELD OF NORTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 54631 ) |
| Policy contract number | 075879 |
| Policy instance | 1 |
| Insurance contract or identification number | 075879 | | Number of Individuals Covered | 222 | | Insurance policy start date | 2014-04-01 | | Insurance policy end date | 2015-03-31 | | Total amount of commissions paid to insurance broker | USD $34,945 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $226,957 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $34,945 | | Insurance broker organization code? | 3 | | Insurance broker name | WILLIFORD INS GROUP |
|
| USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 ) |
| Policy contract number | 50018988 |
| Policy instance | 3 |
| Insurance contract or identification number | 50018988 | | Number of Individuals Covered | 74 | | Insurance policy start date | 2014-04-01 | | Insurance policy end date | 2015-03-31 | | Total amount of commissions paid to insurance broker | USD $3,691 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $19,426 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,914 | | Insurance broker name | MOSAIC GROUP SERVICES |
|
| USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 ) |
| Policy contract number | 50018988 |
| Policy instance | 3 |
| Insurance contract or identification number | 50018988 | | Number of Individuals Covered | 187 | | Insurance policy start date | 2013-07-01 | | Insurance policy end date | 2014-03-31 | | Total amount of commissions paid to insurance broker | USD $1,591 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACC DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $7,956 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,193 | | Insurance broker name | MOSAIC GROUP SERVICES |
|
| COMPANION LIFE (National Association of Insurance Commissioners NAIC id number: 77828 ) |
| Policy contract number | 9072571381000 |
| Policy instance | 2 |
| Insurance contract or identification number | 9072571381000 | | Number of Individuals Covered | 172 | | Insurance policy start date | 2013-04-01 | | Insurance policy end date | 2013-06-30 | | Total amount of commissions paid to insurance broker | USD $2,652 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD & D, SHORT TERM DISABILITY | | Welfare Benefit Premiums Paid to Carrier | USD $7,924 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,768 | | Insurance broker organization code? | 3 | | Insurance broker name | THE CASON GROUP |
|
| USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 ) |
| Policy contract number | 50018988 |
| Policy instance | 5 |
| Insurance contract or identification number | 50018988 | | Number of Individuals Covered | 123 | | Insurance policy start date | 2013-07-01 | | Insurance policy end date | 2014-03-31 | | Total amount of commissions paid to insurance broker | USD $3,232 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Other welfare benefits provided | SHORT TERM DISABILITY | | Welfare Benefit Premiums Paid to Carrier | USD $16,161 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,424 | | Insurance broker name | MOSAIC GROUP SERVICES |
|
| USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 ) |
| Policy contract number | 50018988 |
| Policy instance | 6 |
| Insurance contract or identification number | 50018988 | | Number of Individuals Covered | 76 | | Insurance policy start date | 2013-07-01 | | Insurance policy end date | 2014-03-31 | | Total amount of commissions paid to insurance broker | USD $3,137 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $12,546 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,882 | | Insurance broker name | MOSAIC GROUP SERVICES |
|
| BLUECROSS BLUESHIELD OF NORTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 54631 ) |
| Policy contract number | 075879 |
| Policy instance | 1 |
| Insurance contract or identification number | 075879 | | Number of Individuals Covered | 138 | | Insurance policy start date | 2013-04-01 | | Insurance policy end date | 2014-03-31 | | Total amount of commissions paid to insurance broker | USD $22,855 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $139,099 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $22,855 | | Insurance broker organization code? | 3 | | Insurance broker name | WILLIFORD INS GROUP |
|
| USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 ) |
| Policy contract number | 50018988 |
| Policy instance | 4 |
| Insurance contract or identification number | 50018988 | | Number of Individuals Covered | 60 | | Insurance policy start date | 2013-07-01 | | Insurance policy end date | 2014-03-31 | | Total amount of commissions paid to insurance broker | USD $2,514 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $13,235 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,985 | | Insurance broker name | MOSAIC GROUP SERVICES |
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| COMPANION LIFE (National Association of Insurance Commissioners NAIC id number: 77828 ) |
| Policy contract number | 9072571381001 |
| Policy instance | 3 |
| Insurance contract or identification number | 9072571381001 | | Insurance policy start date | 2012-04-01 | | Insurance policy end date | 2013-03-31 | | Total amount of commissions paid to insurance broker | USD $3,940 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | VOLUNTARY AD & D | | Welfare Benefit Premiums Paid to Carrier | USD $17,514 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,627 | | Insurance broker name | THE CASON GROUP |
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| COMPANION LIFE (National Association of Insurance Commissioners NAIC id number: 77828 ) |
| Policy contract number | 9072571381000 |
| Policy instance | 2 |
| Insurance contract or identification number | 9072571381000 | | Insurance policy start date | 2012-04-01 | | Insurance policy end date | 2013-03-31 | | Total amount of commissions paid to insurance broker | USD $10,460 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD & D, SHORT TERM DISABILITY | | Welfare Benefit Premiums Paid to Carrier | USD $46,486 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,973 | | Insurance broker organization code? | 3 | | Insurance broker name | THE CASON GROUP |
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| BLUECROSS BLUESHIELD OF NORTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 54631 ) |
| Policy contract number | 075879 |
| Policy instance | 1 |
| Insurance contract or identification number | 075879 | | Insurance policy start date | 2012-04-01 | | Insurance policy end date | 2013-03-31 | | Total amount of commissions paid to insurance broker | USD $25,670 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $145,411 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $25,670 | | Insurance broker organization code? | 3 | | Insurance broker name | WILLIFORD INS GROUP |
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| COMPANION LIFE (National Association of Insurance Commissioners NAIC id number: 77828 ) |
| Policy contract number | 9072571381001 |
| Policy instance | 4 |
| Insurance contract or identification number | 9072571381001 | | Number of Individuals Covered | 65 | | Insurance policy start date | 2011-04-01 | | Insurance policy end date | 2012-03-31 | | Total amount of commissions paid to insurance broker | USD $3,124 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | VOLUNTARY AD & D | | Welfare Benefit Premiums Paid to Carrier | USD $13,885 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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| COMPANION LIFE (National Association of Insurance Commissioners NAIC id number: 77828 ) |
| Policy contract number | 9072571381000 |
| Policy instance | 3 |
| Insurance contract or identification number | 9072571381000 | | Number of Individuals Covered | 162 | | Insurance policy start date | 2011-04-01 | | Insurance policy end date | 2012-03-31 | | Total amount of commissions paid to insurance broker | USD $9,097 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $40,431 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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| NATIONAL UNION (National Association of Insurance Commissioners NAIC id number: 19445 ) |
| Policy contract number | 280-9947 |
| Policy instance | 2 |
| Insurance contract or identification number | 280-9947 | | Number of Individuals Covered | 103 | | Insurance policy start date | 2011-04-01 | | Insurance policy end date | 2012-03-31 | | Total amount of commissions paid to insurance broker | USD $21,282 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Welfare Benefit Premiums Paid to Carrier | USD $141,881 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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| NATIONAL UNION (National Association of Insurance Commissioners NAIC id number: 19445 ) |
| Policy contract number | 949-0259 |
| Policy instance | 1 |
| Insurance contract or identification number | 949-0259 | | Number of Individuals Covered | 103 | | Insurance policy start date | 2011-04-01 | | Insurance policy end date | 2012-03-31 | | Total amount of commissions paid to insurance broker | USD $1,918 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Other welfare benefits provided | ORGAN TRANSPLANT | | Welfare Benefit Premiums Paid to Carrier | USD $19,176 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 239269 |
| Policy instance | 1 |
| Insurance contract or identification number | 239269 | | Number of Individuals Covered | 103 | | Insurance policy start date | 2010-01-01 | | Insurance policy end date | 2010-12-31 | | Total amount of commissions paid to insurance broker | USD $2,217 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $22,169 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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| NATIONAL UNION (National Association of Insurance Commissioners NAIC id number: 19445 ) |
| Policy contract number | 280-9660 |
| Policy instance | 3 |
| Insurance contract or identification number | 280-9660 | | Number of Individuals Covered | 121 | | Insurance policy start date | 2010-04-01 | | Insurance policy end date | 2011-03-31 | | Total amount of commissions paid to insurance broker | USD $18,498 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Welfare Benefit Premiums Paid to Carrier | USD $123,320 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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| EASTERN LIFE & HEALTH INSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 62804 ) |
| Policy contract number | 39797 |
| Policy instance | 4 |
| Insurance contract or identification number | 39797 | | Number of Individuals Covered | 252 | | Insurance policy start date | 2009-07-01 | | Insurance policy end date | 2010-06-30 | | Total amount of commissions paid to insurance broker | USD $10,771 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $73,629 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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| SECURITY LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68721 ) |
| Policy contract number | 39797 |
| Policy instance | 5 |
| Insurance contract or identification number | 39797 | | Number of Individuals Covered | 169 | | Insurance policy start date | 2010-04-01 | | Insurance policy end date | 2010-12-31 | | Total amount of commissions paid to insurance broker | USD $6,234 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $46,692 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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| COMPANION LIFE (National Association of Insurance Commissioners NAIC id number: 77828 ) |
| Policy contract number | 9072571381 |
| Policy instance | 6 |
| Insurance contract or identification number | 9072571381 | | Number of Individuals Covered | 169 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2011-03-31 | | Total amount of commissions paid to insurance broker | USD $846 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD & D | | Welfare Benefit Premiums Paid to Carrier | USD $15,009 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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| COMPANION LIFE (National Association of Insurance Commissioners NAIC id number: 77828 ) |
| Policy contract number | 9072571381 001 |
| Policy instance | 7 |
| Insurance contract or identification number | 9072571381 001 | | Number of Individuals Covered | 76 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2011-03-31 | | Total amount of commissions paid to insurance broker | USD $978 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | VOLUNTARY AD & D | | Welfare Benefit Premiums Paid to Carrier | USD $5,605 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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| NATIONAL UNION (National Association of Insurance Commissioners NAIC id number: 19445 ) |
| Policy contract number | 280-8361 |
| Policy instance | 2 |
| Insurance contract or identification number | 280-8361 | | Number of Individuals Covered | 121 | | Insurance policy start date | 2010-04-01 | | Insurance policy end date | 2011-03-31 | | Total amount of commissions paid to insurance broker | USD $1,608 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Other welfare benefits provided | ORGAN TRANSPLANT | | Welfare Benefit Premiums Paid to Carrier | USD $16,079 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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