A. G. RHODES HEALTH AND REHAB MANAGEMENT, INC. has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan A. G. RHODES HEALTH AND REHAB MANAGEMENT, INC. EMPLOYEE BENEFITS PLAN
401k plan membership statisitcs for A. G. RHODES HEALTH AND REHAB MANAGEMENT, INC. EMPLOYEE BENEFITS PLAN
| Measure | Date | Value |
|---|
| 2022: A. G. RHODES HEALTH AND REHAB MANAGEMENT, INC. EMPLOYEE BENEFITS PLAN 2022 401k membership |
|---|
| Total participants, beginning-of-year | 2022-01-01 | 234 |
| Total number of active participants reported on line 7a of the Form 5500 | 2022-01-01 | 191 |
| Number of retired or separated participants receiving benefits | 2022-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2022-01-01 | 0 |
| Total of all active and inactive participants | 2022-01-01 | 191 |
| Number of employers contributing to the scheme | 2022-01-01 | 0 |
| 2021: A. G. RHODES HEALTH AND REHAB MANAGEMENT, INC. EMPLOYEE BENEFITS PLAN 2021 401k membership |
|---|
| Total participants, beginning-of-year | 2021-01-01 | 284 |
| Total number of active participants reported on line 7a of the Form 5500 | 2021-01-01 | 234 |
| Total of all active and inactive participants | 2021-01-01 | 234 |
| 2020: A. G. RHODES HEALTH AND REHAB MANAGEMENT, INC. EMPLOYEE BENEFITS PLAN 2020 401k membership |
|---|
| Total participants, beginning-of-year | 2020-01-01 | 363 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-01-01 | 284 |
| Number of retired or separated participants receiving benefits | 2020-01-01 | 0 |
| Total of all active and inactive participants | 2020-01-01 | 284 |
| 2019: A. G. RHODES HEALTH AND REHAB MANAGEMENT, INC. EMPLOYEE BENEFITS PLAN 2019 401k membership |
|---|
| Total participants, beginning-of-year | 2019-08-01 | 368 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-08-01 | 363 |
| Total of all active and inactive participants | 2019-08-01 | 363 |
| 2018: A. G. RHODES HEALTH AND REHAB MANAGEMENT, INC. EMPLOYEE BENEFITS PLAN 2018 401k membership |
|---|
| Total participants, beginning-of-year | 2018-08-01 | 376 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-08-01 | 368 |
| Total of all active and inactive participants | 2018-08-01 | 368 |
| 2017: A. G. RHODES HEALTH AND REHAB MANAGEMENT, INC. EMPLOYEE BENEFITS PLAN 2017 401k membership |
|---|
| Total participants, beginning-of-year | 2017-08-01 | 349 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-08-01 | 374 |
| Number of retired or separated participants receiving benefits | 2017-08-01 | 2 |
| Total of all active and inactive participants | 2017-08-01 | 376 |
| 2016: A. G. RHODES HEALTH AND REHAB MANAGEMENT, INC. EMPLOYEE BENEFITS PLAN 2016 401k membership |
|---|
| Total participants, beginning-of-year | 2016-08-01 | 378 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-08-01 | 347 |
| Number of retired or separated participants receiving benefits | 2016-08-01 | 2 |
| Number of other retired or separated participants entitled to future benefits | 2016-08-01 | 0 |
| Total of all active and inactive participants | 2016-08-01 | 349 |
| 2015: A. G. RHODES HEALTH AND REHAB MANAGEMENT, INC. EMPLOYEE BENEFITS PLAN 2015 401k membership |
|---|
| Total participants, beginning-of-year | 2015-08-01 | 407 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-08-01 | 376 |
| Number of retired or separated participants receiving benefits | 2015-08-01 | 2 |
| Number of other retired or separated participants entitled to future benefits | 2015-08-01 | 0 |
| Total of all active and inactive participants | 2015-08-01 | 378 |
| 2014: A. G. RHODES HEALTH AND REHAB MANAGEMENT, INC. EMPLOYEE BENEFITS PLAN 2014 401k membership |
|---|
| Total participants, beginning-of-year | 2014-08-01 | 478 |
| Total number of active participants reported on line 7a of the Form 5500 | 2014-08-01 | 387 |
| Number of retired or separated participants receiving benefits | 2014-08-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2014-08-01 | 0 |
| Total of all active and inactive participants | 2014-08-01 | 387 |
| 2013: A. G. RHODES HEALTH AND REHAB MANAGEMENT, INC. EMPLOYEE BENEFITS PLAN 2013 401k membership |
|---|
| Total participants, beginning-of-year | 2013-08-01 | 371 |
| Total number of active participants reported on line 7a of the Form 5500 | 2013-08-01 | 385 |
| Number of retired or separated participants receiving benefits | 2013-08-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2013-08-01 | 0 |
| Total of all active and inactive participants | 2013-08-01 | 385 |
| 2012: A. G. RHODES HEALTH AND REHAB MANAGEMENT, INC. EMPLOYEE BENEFITS PLAN 2012 401k membership |
|---|
| Total participants, beginning-of-year | 2012-08-01 | 342 |
| Total number of active participants reported on line 7a of the Form 5500 | 2012-08-01 | 371 |
| Number of retired or separated participants receiving benefits | 2012-08-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2012-08-01 | 0 |
| Total of all active and inactive participants | 2012-08-01 | 371 |
| 2011: A. G. RHODES HEALTH AND REHAB MANAGEMENT, INC. EMPLOYEE BENEFITS PLAN 2011 401k membership |
|---|
| Total participants, beginning-of-year | 2011-08-01 | 580 |
| Total number of active participants reported on line 7a of the Form 5500 | 2011-08-01 | 541 |
| Number of retired or separated participants receiving benefits | 2011-08-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2011-08-01 | 0 |
| Total of all active and inactive participants | 2011-08-01 | 541 |
| 2010: A. G. RHODES HEALTH AND REHAB MANAGEMENT, INC. EMPLOYEE BENEFITS PLAN 2010 401k membership |
|---|
| Total participants, beginning-of-year | 2010-08-01 | 378 |
| Total number of active participants reported on line 7a of the Form 5500 | 2010-08-01 | 580 |
| Total of all active and inactive participants | 2010-08-01 | 580 |
| 2009: A. G. RHODES HEALTH AND REHAB MANAGEMENT, INC. EMPLOYEE BENEFITS PLAN 2009 401k membership |
|---|
| Total participants, beginning-of-year | 2009-08-01 | 374 |
| Total number of active participants reported on line 7a of the Form 5500 | 2009-08-01 | 378 |
| Number of retired or separated participants receiving benefits | 2009-08-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2009-08-01 | 0 |
| Total of all active and inactive participants | 2009-08-01 | 378 |
| Total participants | 2009-08-01 | 378 |
| 2022: A. G. RHODES HEALTH AND REHAB MANAGEMENT, INC. EMPLOYEE BENEFITS PLAN 2022 form 5500 responses |
|---|
| 2022-01-01 | Type of plan entity | Single employer plan |
| 2022-01-01 | Plan funding arrangement – Insurance | Yes |
| 2022-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2022-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2022-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2021: A. G. RHODES HEALTH AND REHAB MANAGEMENT, INC. EMPLOYEE BENEFITS PLAN 2021 form 5500 responses |
|---|
| 2021-01-01 | Type of plan entity | Single employer plan |
| 2021-01-01 | Submission has been amended | No |
| 2021-01-01 | This submission is the final filing | No |
| 2021-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2021-01-01 | Plan is a collectively bargained plan | No |
| 2021-01-01 | Plan funding arrangement – Insurance | Yes |
| 2021-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2021-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2021-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2020: A. G. RHODES HEALTH AND REHAB MANAGEMENT, INC. EMPLOYEE BENEFITS PLAN 2020 form 5500 responses |
|---|
| 2020-01-01 | Type of plan entity | Single employer plan |
| 2020-01-01 | Submission has been amended | No |
| 2020-01-01 | This submission is the final filing | No |
| 2020-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2020-01-01 | Plan is a collectively bargained plan | No |
| 2020-01-01 | Plan funding arrangement – Insurance | Yes |
| 2020-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2020-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2020-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2019: A. G. RHODES HEALTH AND REHAB MANAGEMENT, INC. EMPLOYEE BENEFITS PLAN 2019 form 5500 responses |
|---|
| 2019-08-01 | Type of plan entity | Single employer plan |
| 2019-08-01 | Submission has been amended | No |
| 2019-08-01 | This submission is the final filing | No |
| 2019-08-01 | This return/report is a short plan year return/report (less than 12 months) | Yes |
| 2019-08-01 | Plan is a collectively bargained plan | No |
| 2019-08-01 | Plan funding arrangement – Insurance | Yes |
| 2019-08-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2019-08-01 | Plan benefit arrangement – Insurance | Yes |
| 2019-08-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2018: A. G. RHODES HEALTH AND REHAB MANAGEMENT, INC. EMPLOYEE BENEFITS PLAN 2018 form 5500 responses |
|---|
| 2018-08-01 | Type of plan entity | Single employer plan |
| 2018-08-01 | Submission has been amended | No |
| 2018-08-01 | This submission is the final filing | No |
| 2018-08-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2018-08-01 | Plan is a collectively bargained plan | No |
| 2018-08-01 | Plan funding arrangement – Insurance | Yes |
| 2018-08-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2018-08-01 | Plan benefit arrangement – Insurance | Yes |
| 2018-08-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2017: A. G. RHODES HEALTH AND REHAB MANAGEMENT, INC. EMPLOYEE BENEFITS PLAN 2017 form 5500 responses |
|---|
| 2017-08-01 | Type of plan entity | Single employer plan |
| 2017-08-01 | Submission has been amended | No |
| 2017-08-01 | This submission is the final filing | No |
| 2017-08-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2017-08-01 | Plan is a collectively bargained plan | No |
| 2017-08-01 | Plan funding arrangement – Insurance | Yes |
| 2017-08-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2017-08-01 | Plan benefit arrangement – Insurance | Yes |
| 2017-08-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2016: A. G. RHODES HEALTH AND REHAB MANAGEMENT, INC. EMPLOYEE BENEFITS PLAN 2016 form 5500 responses |
|---|
| 2016-08-01 | Type of plan entity | Single employer plan |
| 2016-08-01 | Submission has been amended | No |
| 2016-08-01 | This submission is the final filing | No |
| 2016-08-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2016-08-01 | Plan is a collectively bargained plan | No |
| 2016-08-01 | Plan funding arrangement – Insurance | Yes |
| 2016-08-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2016-08-01 | Plan benefit arrangement – Insurance | Yes |
| 2016-08-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2015: A. G. RHODES HEALTH AND REHAB MANAGEMENT, INC. EMPLOYEE BENEFITS PLAN 2015 form 5500 responses |
|---|
| 2015-08-01 | Type of plan entity | Single employer plan |
| 2015-08-01 | Submission has been amended | No |
| 2015-08-01 | This submission is the final filing | No |
| 2015-08-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2015-08-01 | Plan is a collectively bargained plan | No |
| 2015-08-01 | Plan funding arrangement – Insurance | Yes |
| 2015-08-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2015-08-01 | Plan benefit arrangement – Insurance | Yes |
| 2015-08-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2014: A. G. RHODES HEALTH AND REHAB MANAGEMENT, INC. EMPLOYEE BENEFITS PLAN 2014 form 5500 responses |
|---|
| 2014-08-01 | Type of plan entity | Single employer plan |
| 2014-08-01 | Submission has been amended | No |
| 2014-08-01 | This submission is the final filing | No |
| 2014-08-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2014-08-01 | Plan is a collectively bargained plan | No |
| 2014-08-01 | Plan funding arrangement – Insurance | Yes |
| 2014-08-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2014-08-01 | Plan benefit arrangement – Insurance | Yes |
| 2014-08-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2013: A. G. RHODES HEALTH AND REHAB MANAGEMENT, INC. EMPLOYEE BENEFITS PLAN 2013 form 5500 responses |
|---|
| 2013-08-01 | Type of plan entity | Single employer plan |
| 2013-08-01 | Submission has been amended | No |
| 2013-08-01 | This submission is the final filing | No |
| 2013-08-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2013-08-01 | Plan is a collectively bargained plan | No |
| 2013-08-01 | Plan funding arrangement – Insurance | Yes |
| 2013-08-01 | Plan benefit arrangement – Insurance | Yes |
| 2012: A. G. RHODES HEALTH AND REHAB MANAGEMENT, INC. EMPLOYEE BENEFITS PLAN 2012 form 5500 responses |
|---|
| 2012-08-01 | Type of plan entity | Single employer plan |
| 2012-08-01 | Submission has been amended | No |
| 2012-08-01 | This submission is the final filing | No |
| 2012-08-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2012-08-01 | Plan is a collectively bargained plan | No |
| 2012-08-01 | Plan funding arrangement – Insurance | Yes |
| 2012-08-01 | Plan benefit arrangement – Insurance | Yes |
| 2011: A. G. RHODES HEALTH AND REHAB MANAGEMENT, INC. EMPLOYEE BENEFITS PLAN 2011 form 5500 responses |
|---|
| 2011-08-01 | Type of plan entity | Single employer plan |
| 2011-08-01 | Submission has been amended | No |
| 2011-08-01 | This submission is the final filing | No |
| 2011-08-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2011-08-01 | Plan is a collectively bargained plan | No |
| 2011-08-01 | Plan funding arrangement – Insurance | Yes |
| 2011-08-01 | Plan benefit arrangement – Insurance | Yes |
| 2010: A. G. RHODES HEALTH AND REHAB MANAGEMENT, INC. EMPLOYEE BENEFITS PLAN 2010 form 5500 responses |
|---|
| 2010-08-01 | Type of plan entity | Single employer plan |
| 2010-08-01 | Submission has been amended | No |
| 2010-08-01 | This submission is the final filing | No |
| 2010-08-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2010-08-01 | Plan is a collectively bargained plan | No |
| 2010-08-01 | Plan funding arrangement – Insurance | Yes |
| 2010-08-01 | Plan benefit arrangement – Insurance | Yes |
| 2009: A. G. RHODES HEALTH AND REHAB MANAGEMENT, INC. EMPLOYEE BENEFITS PLAN 2009 form 5500 responses |
|---|
| 2009-08-01 | Type of plan entity | Single employer plan |
| 2009-08-01 | This submission is the final filing | No |
| 2009-08-01 | Plan funding arrangement – Insurance | Yes |
| 2009-08-01 | Plan benefit arrangement – Insurance | Yes |
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | LK965085 |
| Policy instance | 3 |
| Insurance contract or identification number | LK965085 | | Number of Individuals Covered | 191 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $17,279 | | Total amount of fees paid to insurance company | USD $12,279 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | EMPLOYEE ASSISTANCE PROGRAM,ACCIDENTAL DEATH AND DISMEMBERMENT,ACCIDENT,CRITICAL ILLNESS,HOSPITAL | | Welfare Benefit Premiums Paid to Carrier | USD $244,752 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $17,279 | | Amount paid for insurance broker fees | 12279 | | Additional information about fees paid to insurance broker | OVERRIDE, SERVICE FEES, OVERRIDE | | Insurance broker organization code? | 3 |
|
| KAISER FOUNDATION HEALTH PLAN OF GEORGIA INC. (National Association of Insurance Commissioners NAIC id number: 96237 ) |
| Policy contract number | 10417 |
| Policy instance | 2 |
| Insurance contract or identification number | 10417 | | Number of Individuals Covered | 356 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $100,816 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $2,016,318 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $100,816 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
| Policy contract number | 3339969 |
| Policy instance | 1 |
| Insurance contract or identification number | 3339969 | | Number of Individuals Covered | 191 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $13,879 | | Total amount of fees paid to insurance company | USD $3,546 | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $140,193 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $13,879 | | Amount paid for insurance broker fees | 3546 | | Additional information about fees paid to insurance broker | GENERAL AGENT PAYMENTS | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | OK968929 |
| Policy instance | 1 |
| Insurance contract or identification number | OK968929 | | Number of Individuals Covered | 234 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $1,222 | | Total amount of fees paid to insurance company | USD $244 | | Other welfare benefits provided | ACCIDENTAL DEATH | | Welfare Benefit Premiums Paid to Carrier | USD $4,321 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,222 | | Amount paid for insurance broker fees | 244 | | Additional information about fees paid to insurance broker | SERVICE FEES | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | AI961277 |
| Policy instance | 2 |
| Insurance contract or identification number | AI961277 | | Number of Individuals Covered | 49 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $1,465 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | ACCIDENTAL INJURY | | Welfare Benefit Premiums Paid to Carrier | USD $9,767 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,465 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | CI961223 |
| Policy instance | 3 |
| Insurance contract or identification number | CI961223 | | Number of Individuals Covered | 50 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $14,851 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | CRITICAL ILLNESS | | Welfare Benefit Premiums Paid to Carrier | USD $14,851 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $14,851 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
| Policy contract number | 3339969 |
| Policy instance | 4 |
| Insurance contract or identification number | 3339969 | | Number of Individuals Covered | 207 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $14,921 | | Total amount of fees paid to insurance company | USD $3,814 | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $150,907 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $14,921 | | Amount paid for insurance broker fees | 3814 | | Additional information about fees paid to insurance broker | GENERAL AGENT PAYMENTS | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | LK965085 |
| Policy instance | 5 |
| Insurance contract or identification number | LK965085 | | Number of Individuals Covered | 114 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $1,531 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $53,476 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $0 | | Amount paid for insurance broker fees | 1531 | | Additional information about fees paid to insurance broker | SALES AND SERVICE OVERRIDE | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | HC960604 |
| Policy instance | 6 |
| Insurance contract or identification number | HC960604 | | Number of Individuals Covered | 41 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $2,014 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | VOLUNTARY HOSPITAL CARE | | Welfare Benefit Premiums Paid to Carrier | USD $13,428 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,014 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | LK752036 |
| Policy instance | 7 |
| Insurance contract or identification number | LK752036 | | Number of Individuals Covered | 209 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $3,186 | | Total amount of fees paid to insurance company | USD $4,323 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $42,987 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,186 | | Amount paid for insurance broker fees | 4323 | | Additional information about fees paid to insurance broker | SALES AND SERVICE OVERRIDE | | Insurance broker organization code? | 3 |
|
| KAISER FOUNDATION HEALTH PLAN OF GEORGIA INC. (National Association of Insurance Commissioners NAIC id number: 96237 ) |
| Policy contract number | 10417 |
| Policy instance | 8 |
| Insurance contract or identification number | 10417 | | Number of Individuals Covered | 398 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $99,659 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,977,182 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $99,659 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | FLX967414 |
| Policy instance | 9 |
| Insurance contract or identification number | FLX967414 | | Number of Individuals Covered | 209 | | Insurance policy start date | 2021-08-01 | | Insurance policy end date | 2022-07-31 | | Total amount of commissions paid to insurance broker | USD $4,600 | | Total amount of fees paid to insurance company | USD $3,929 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | SUPPLEMENTAL & DEPENDENT LIFE | | Welfare Benefit Premiums Paid to Carrier | USD $33,162 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,600 | | Amount paid for insurance broker fees | 3929 | | Additional information about fees paid to insurance broker | SALES AND SERVICE OVERRIDE | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | HC960604 |
| Policy instance | 1 |
| Insurance contract or identification number | HC960604 | | Number of Individuals Covered | 43 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $2,014 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | VOLUNTARY HOSPITAL CARE | | Welfare Benefit Premiums Paid to Carrier | USD $13,428 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,014 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | LK965085 |
| Policy instance | 2 |
| Insurance contract or identification number | LK965085 | | Number of Individuals Covered | 133 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $4,320 | | Total amount of fees paid to insurance company | USD $863 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $58,085 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,320 | | Amount paid for insurance broker fees | 863 | | Additional information about fees paid to insurance broker | SALES & SERVICE OVERRIDE | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | LK752036 |
| Policy instance | 3 |
| Insurance contract or identification number | LK752036 | | Number of Individuals Covered | 283 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $3,488 | | Total amount of fees paid to insurance company | USD $3,776 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $78,299 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,488 | | Amount paid for insurance broker fees | 3776 | | Additional information about fees paid to insurance broker | SALES & SERVICE OVERRIDE | | Insurance broker organization code? | 3 |
|
| KAISER FOUNDATION HEALTH PLAN OF GEORGIA INC. (National Association of Insurance Commissioners NAIC id number: 96237 ) |
| Policy contract number | 10417 |
| Policy instance | 4 |
| Insurance contract or identification number | 10417 | | Number of Individuals Covered | 425 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $106,652 | | Total amount of fees paid to insurance company | USD $243 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $2,128,240 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $106,652 | | Amount paid for insurance broker fees | 243 | | Additional information about fees paid to insurance broker | NON-MONETARY COMPENSATION | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | OK968929 |
| Policy instance | 5 |
| Insurance contract or identification number | OK968929 | | Number of Individuals Covered | 284 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $1,251 | | Total amount of fees paid to insurance company | USD $270 | | Other welfare benefits provided | ACCIDENTAL DEATH | | Welfare Benefit Premiums Paid to Carrier | USD $8,340 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,251 | | Amount paid for insurance broker fees | 270 | | Additional information about fees paid to insurance broker | SALES & SERVICE OVERRIDE | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | CI961223 |
| Policy instance | 6 |
| Insurance contract or identification number | CI961223 | | Number of Individuals Covered | 48 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $2,228 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | CRITICAL ILLNESS | | Welfare Benefit Premiums Paid to Carrier | USD $14,851 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,228 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
| Policy contract number | 3339969 |
| Policy instance | 7 |
| Insurance contract or identification number | 3339969 | | Number of Individuals Covered | 234 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $5,956 | | Total amount of fees paid to insurance company | USD $4,872 | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $146,274 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,956 | | Amount paid for insurance broker fees | 4872 | | Additional information about fees paid to insurance broker | GENERAL AGENT PAYMENTS | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | FLX967414 |
| Policy instance | 8 |
| Insurance contract or identification number | FLX967414 | | Number of Individuals Covered | 284 | | Insurance policy start date | 2020-08-01 | | Insurance policy end date | 2021-07-31 | | Total amount of commissions paid to insurance broker | USD $5,104 | | Total amount of fees paid to insurance company | USD $2,334 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | SUPPLEMENTAL & DEPENDENT LIFE | | Welfare Benefit Premiums Paid to Carrier | USD $69,319 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,104 | | Amount paid for insurance broker fees | 2334 | | Additional information about fees paid to insurance broker | SALES & SERVICE OVERRIDE | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | AI961277 |
| Policy instance | 9 |
| Insurance contract or identification number | AI961277 | | Number of Individuals Covered | 41 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $1,465 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | ACCIDENTAL INJURY | | Welfare Benefit Premiums Paid to Carrier | USD $9,767 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,465 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| KAISER FOUNDATION HEALTH PLAN OF GEORGIA INC. (National Association of Insurance Commissioners NAIC id number: 96237 ) |
| Policy contract number | 10417 |
| Policy instance | 8 |
| Insurance contract or identification number | 10417 | | Number of Individuals Covered | 398 | | Insurance policy start date | 2019-08-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $44,094 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $881,884 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $44,094 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 ) |
| Policy contract number | LG601/02/03/04 |
| Policy instance | 7 |
| Insurance contract or identification number | LG601/02/03/04 | | Number of Individuals Covered | 267 | | Insurance policy start date | 2019-08-01 | | Insurance policy end date | 2020-07-31 | | Total amount of commissions paid to insurance broker | USD $7,195 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | ACCIDENT, CI, DISABILITY,HOSPITAL, UNIVERSAL LIFE | | Welfare Benefit Premiums Paid to Carrier | USD $38,947 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,048 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | FLX967414 |
| Policy instance | 6 |
| Insurance contract or identification number | FLX967414 | | Number of Individuals Covered | 313 | | Insurance policy start date | 2019-08-01 | | Insurance policy end date | 2020-07-31 | | Total amount of commissions paid to insurance broker | USD $1,233 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | SUPPLEMENTAL & DEPENDENT LIFE | | Welfare Benefit Premiums Paid to Carrier | USD $27,635 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,233 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | LK965085 |
| Policy instance | 5 |
| Insurance contract or identification number | LK965085 | | Number of Individuals Covered | 103 | | Insurance policy start date | 2019-08-01 | | Insurance policy end date | 2020-07-31 | | Total amount of commissions paid to insurance broker | USD $799 | | Total amount of fees paid to insurance company | USD $0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $17,341 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $799 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| BLUE CROSS BLUE SHIELD OF GEORGIA INC. (G0386) (National Association of Insurance Commissioners NAIC id number: 96962 ) |
| Policy contract number | GA9491 |
| Policy instance | 4 |
| Insurance contract or identification number | GA9491 | | Insurance policy start date | 2019-08-01 | | Insurance policy end date | 2019-12-31 | | Health Insurance Welfare Benefit | Yes | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | LK752036 |
| Policy instance | 3 |
| Insurance contract or identification number | LK752036 | | Number of Individuals Covered | 363 | | Insurance policy start date | 2019-08-01 | | Insurance policy end date | 2020-07-31 | | Total amount of commissions paid to insurance broker | USD $311 | | Total amount of fees paid to insurance company | USD $0 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $44,606 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $311 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | OK968929 |
| Policy instance | 2 |
| Insurance contract or identification number | OK968929 | | Number of Individuals Covered | 313 | | Insurance policy start date | 2019-08-01 | | Insurance policy end date | 2020-07-31 | | Total amount of commissions paid to insurance broker | USD $452 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | ACCIDENTAL DEATH | | Welfare Benefit Premiums Paid to Carrier | USD $3,015 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $452 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
| Policy contract number | 3339969 |
| Policy instance | 1 |
| Insurance contract or identification number | 3339969 | | Insurance policy start date | 2019-08-01 | | Insurance policy end date | 2020-07-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | LK965085 |
| Policy instance | 3 |
| Insurance contract or identification number | LK965085 | | Number of Individuals Covered | 106 | | Insurance policy start date | 2018-08-01 | | Insurance policy end date | 2019-07-31 | | Total amount of commissions paid to insurance broker | USD $4,172 | | Total amount of fees paid to insurance company | USD $895 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $46,751 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,027 | | Amount paid for insurance broker fees | 617 | | Additional information about fees paid to insurance broker | SALES & SERVICE OVERRIDE | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | FLX967414 |
| Policy instance | 4 |
| Insurance contract or identification number | FLX967414 | | Number of Individuals Covered | 304 | | Insurance policy start date | 2018-08-01 | | Insurance policy end date | 2019-07-31 | | Total amount of commissions paid to insurance broker | USD $5,311 | | Total amount of fees paid to insurance company | USD $1,347 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | SUPPLEMENTAL & DEPENDENT LIFE | | Welfare Benefit Premiums Paid to Carrier | USD $72,761 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,557 | | Amount paid for insurance broker fees | 920 | | Additional information about fees paid to insurance broker | SALES & SERVICE OVERRIDE | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | LK752036 |
| Policy instance | 5 |
| Insurance contract or identification number | LK752036 | | Number of Individuals Covered | 368 | | Insurance policy start date | 2018-08-01 | | Insurance policy end date | 2019-07-31 | | Total amount of commissions paid to insurance broker | USD $3,948 | | Total amount of fees paid to insurance company | USD $2,115 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $112,827 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,049 | | Amount paid for insurance broker fees | 1479 | | Additional information about fees paid to insurance broker | SALES & SERVICE OVERRIDE | | Insurance broker organization code? | 3 |
|
| AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 ) |
| Policy contract number | LG601/02/03/04 |
| Policy instance | 7 |
| Insurance contract or identification number | LG601/02/03/04 | | Number of Individuals Covered | 200 | | Insurance policy start date | 2018-08-01 | | Insurance policy end date | 2019-07-31 | | Total amount of commissions paid to insurance broker | USD $1,160 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | HOSPITAL INDEMNITY | | Welfare Benefit Premiums Paid to Carrier | USD $31,538 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $753 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | OK968929 |
| Policy instance | 8 |
| Insurance contract or identification number | OK968929 | | Number of Individuals Covered | 304 | | Insurance policy start date | 2018-08-01 | | Insurance policy end date | 2019-07-31 | | Total amount of commissions paid to insurance broker | USD $1,221 | | Total amount of fees paid to insurance company | USD $153 | | Other welfare benefits provided | ACCIDENTAL DEATH | | Welfare Benefit Premiums Paid to Carrier | USD $8,135 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $354 | | Amount paid for insurance broker fees | 108 | | Additional information about fees paid to insurance broker | SALES & SERVICE OVERRIDE | | Insurance broker organization code? | 3 |
|
| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
| Policy contract number | 3339969 |
| Policy instance | 2 |
| Insurance contract or identification number | 3339969 | | Number of Individuals Covered | 253 | | Insurance policy start date | 2018-08-01 | | Insurance policy end date | 2019-07-31 | | Total amount of commissions paid to insurance broker | USD $7,397 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $179,542 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,212 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| KAISER FOUNDATION HEALTH PLAN OF GEORGIA INC. (National Association of Insurance Commissioners NAIC id number: 96237 ) |
| Policy contract number | 10417 |
| Policy instance | 1 |
| Insurance contract or identification number | 10417 | | Number of Individuals Covered | 424 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-07-31 | | Total amount of commissions paid to insurance broker | USD $56,289 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,125,770 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $56,289 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| BLUE CROSS BLUE SHIELD OF GEORGIA INC. (G0386) (National Association of Insurance Commissioners NAIC id number: 96962 ) |
| Policy contract number | GA9491 |
| Policy instance | 6 |
| Insurance contract or identification number | GA9491 | | Number of Individuals Covered | 847 | | Insurance policy start date | 2018-08-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $46,006 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $854,279 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,700 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
| Policy contract number | 3339969 |
| Policy instance | 7 |
| Insurance contract or identification number | 3339969 | | Number of Individuals Covered | 276 | | Insurance policy start date | 2017-08-01 | | Insurance policy end date | 2018-07-31 | | Total amount of commissions paid to insurance broker | USD $6,967 | | Total amount of fees paid to insurance company | USD $5,052 | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $177,813 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | FLX967414 |
| Policy instance | 1 |
| Insurance contract or identification number | FLX967414 | | Number of Individuals Covered | 339 | | Insurance policy start date | 2017-08-01 | | Insurance policy end date | 2018-07-31 | | Total amount of commissions paid to insurance broker | USD $4,749 | | Total amount of fees paid to insurance company | USD $990 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | SUPPLEMENTAL & DEPENDENT LIFE | | Welfare Benefit Premiums Paid to Carrier | USD $66,398 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| BLUE CROSS BLUE SHIELD OF GEORGIA INC. (G0386) (National Association of Insurance Commissioners NAIC id number: 96962 ) |
| Policy contract number | GA9491 |
| Policy instance | 2 |
| Insurance contract or identification number | GA9491 | | Number of Individuals Covered | 492 | | Insurance policy start date | 2017-08-01 | | Insurance policy end date | 2018-07-31 | | Total amount of commissions paid to insurance broker | USD $114,596 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $2,442,404 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | LK965085 |
| Policy instance | 3 |
| Insurance contract or identification number | LK965085 | | Number of Individuals Covered | 119 | | Insurance policy start date | 2017-08-01 | | Insurance policy end date | 2018-07-31 | | Total amount of commissions paid to insurance broker | USD $4,085 | | Total amount of fees paid to insurance company | USD $684 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $45,735 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | LK752036 |
| Policy instance | 5 |
| Insurance contract or identification number | LK752036 | | Number of Individuals Covered | 374 | | Insurance policy start date | 2017-08-01 | | Insurance policy end date | 2018-07-31 | | Total amount of commissions paid to insurance broker | USD $3,676 | | Total amount of fees paid to insurance company | USD $1,452 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $105,025 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 ) |
| Policy contract number | OK968929 |
| Policy instance | 4 |
| Insurance contract or identification number | OK968929 | | Number of Individuals Covered | 339 | | Insurance policy start date | 2017-08-01 | | Insurance policy end date | 2018-07-31 | | Total amount of commissions paid to insurance broker | USD $1,130 | | Total amount of fees paid to insurance company | USD $124 | | Other welfare benefits provided | ACCIDENTAL DEATH | | Welfare Benefit Premiums Paid to Carrier | USD $7,787 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 ) |
| Policy contract number | LG601/02/03/04 |
| Policy instance | 6 |
| Insurance contract or identification number | LG601/02/03/04 | | Number of Individuals Covered | 200 | | Insurance policy start date | 2017-08-01 | | Insurance policy end date | 2018-07-31 | | Total amount of commissions paid to insurance broker | USD $16,728 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENT, CRITICAL ILLNESS, HOSPITAL, DISABILITY | | Welfare Benefit Premiums Paid to Carrier | USD $83,037 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| KAISER FOUNDATION HEALTH PLAN OF GEORGIA INC. (National Association of Insurance Commissioners NAIC id number: 96237 ) |
| Policy contract number | 10158 |
| Policy instance | 1 |
| Insurance contract or identification number | 10158 | | Number of Individuals Covered | 648 | | Insurance policy start date | 2015-08-01 | | Insurance policy end date | 2016-07-31 | | Total amount of commissions paid to insurance broker | USD $133,278 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $2,230,374 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $133,278 | | Insurance broker organization code? | 3 | | Insurance broker name | LOCKTON COMPANIES, LLC |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 469681 |
| Policy instance | 2 |
| Insurance contract or identification number | 469681 | | Number of Individuals Covered | 378 | | Insurance policy start date | 2015-08-01 | | Insurance policy end date | 2016-07-31 | | Total amount of commissions paid to insurance broker | USD $26,394 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | 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 | ACCIDENTAL DEATH AND DISMEMBERMENT EMPLOYEE ASSISTANCE PROGRAM | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $432,729 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $26,410 | | Insurance broker organization code? | 3 | | Insurance broker name | NATIONAL BENEFIT CENTER, LLC |
|
| AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 ) |
| Policy contract number | LG601/LG603 |
| Policy instance | 3 |
| Insurance contract or identification number | LG601/LG603 | | Number of Individuals Covered | 39 | | Insurance policy start date | 2015-08-01 | | Insurance policy end date | 2016-07-31 | | Total amount of commissions paid to insurance broker | USD $4,773 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | 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 | CRITICAL ILLNESS, ACCIDENT VOLUNTARY BENEFITS | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $21,053 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,548 | | Insurance broker organization code? | 3 | | Insurance broker name | YONI LABOW |
|
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 835088 |
| Policy instance | 1 |
| Insurance contract or identification number | 835088 | | Number of Individuals Covered | 644 | | Insurance policy start date | 2014-08-01 | | Insurance policy end date | 2015-07-31 | | Total amount of commissions paid to insurance broker | USD $21,175 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $164,222 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $21,175 | | Insurance broker organization code? | 3 | | Insurance broker name | LOCKTON COMPANIES, LLC |
|
| KAISER FOUNDATION HEALTH PLAN OF GEORGIA INC. (National Association of Insurance Commissioners NAIC id number: 96237 ) |
| Policy contract number | 10158 |
| Policy instance | 4 |
| Insurance contract or identification number | 10158 | | Number of Individuals Covered | 713 | | Insurance policy start date | 2014-08-01 | | Insurance policy end date | 2015-07-31 | | Total amount of commissions paid to insurance broker | USD $110,017 | | Total amount of fees paid to insurance company | USD $74,180 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $1,862,575 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $110,017 | | Amount paid for insurance broker fees | 74180 | | Additional information about fees paid to insurance broker | MID GROUP CASE BONUS | | Insurance broker organization code? | 3 | | Insurance broker name | LOCKTON COMPANIES, LLC |
|
| AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 ) |
| Policy contract number | LG601/LG603 |
| Policy instance | 3 |
| Insurance contract or identification number | LG601/LG603 | | Number of Individuals Covered | 40 | | Insurance policy start date | 2014-08-01 | | Insurance policy end date | 2015-07-31 | | Total amount of commissions paid to insurance broker | USD $1,912 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | 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 | VOLUNTARY BENEFITS 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 $25,619 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,907 | | Insurance broker organization code? | 3 | | Insurance broker name | MAIA LABOW |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 469681 |
| Policy instance | 2 |
| Insurance contract or identification number | 469681 | | Number of Individuals Covered | 386 | | Insurance policy start date | 2014-08-01 | | Insurance policy end date | 2015-07-31 | | Total amount of commissions paid to insurance broker | USD $20,755 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | 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 | ACCIDENTAL DEATH AND DISMEMBERMENT EMPLOYEE ASSISTANCE PROGRAM | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $270,618 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $16,368 | | Insurance broker organization code? | 3 | | Insurance broker name | TIS INSURANCE SERVICES, INC. |
|
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 835088 |
| Policy instance | 2 |
| Insurance contract or identification number | 835088 | | Number of Individuals Covered | 647 | | Insurance policy start date | 2013-08-01 | | Insurance policy end date | 2014-07-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $135,377 | | 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 | 469681 |
| Policy instance | 3 |
| Insurance contract or identification number | 469681 | | Number of Individuals Covered | 385 | | Insurance policy start date | 2013-08-01 | | Insurance policy end date | 2014-07-31 | | Total amount of commissions paid to insurance broker | USD $20,842 | | Total amount of fees paid to insurance company | USD $10,769 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $259,584 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $16,389 | | Amount paid for insurance broker fees | 10769 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker organization code? | 3 | | Insurance broker name | LOCKTON COMPANIES, LLC |
|
| AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 ) |
| Policy contract number | LG601/LG603 |
| Policy instance | 4 |
| Insurance contract or identification number | LG601/LG603 | | Number of Individuals Covered | 42 | | Insurance policy start date | 2013-08-01 | | Insurance policy end date | 2014-07-31 | | Total amount of commissions paid to insurance broker | USD $7,631 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | 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 | VOLUNTARY BENEFITS 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 $26,450 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,631 | | Insurance broker organization code? | 3 | | Insurance broker name | HOWARD B. LABOW |
|
| COVENTRY HEALTH CARE OF GEORGIA (National Association of Insurance Commissioners NAIC id number: 95282 ) |
| Policy contract number | 6526460000 |
| Policy instance | 1 |
| Insurance contract or identification number | 6526460000 | | Number of Individuals Covered | 612 | | Insurance policy start date | 2013-08-01 | | Insurance policy end date | 2014-07-31 | | Total amount of commissions paid to insurance broker | USD $76,774 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $1,919,353 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $52,561 | | Insurance broker organization code? | 3 | | Insurance broker name | LOCKTON COMPANIES, LLC |
|
| AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 ) |
| Policy contract number | LG603 |
| Policy instance | 4 |
| Insurance contract or identification number | LG603 | | Number of Individuals Covered | 31 | | Insurance policy start date | 2012-08-01 | | Insurance policy end date | 2013-07-31 | | Total amount of commissions paid to insurance broker | USD $14,988 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | 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, 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 $20,507 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $14,988 | | Insurance broker organization code? | 3 | | Insurance broker name | HOWARD B LABOW |
|
| AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 ) |
| Policy contract number | LG602 |
| Policy instance | 3 |
| Insurance contract or identification number | LG602 | | Number of Individuals Covered | 37 | | Insurance policy start date | 2012-08-01 | | Insurance policy end date | 2013-07-31 | | Total amount of commissions paid to insurance broker | USD $14,085 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | 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, CRITICAL ILLNESS, DISABILITY, SHOP COVERAGE | | 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 $20,319 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $14,085 | | Insurance broker organization code? | 3 | | Insurance broker name | HOWARD B LABOW |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 00469681 |
| Policy instance | 2 |
| Insurance contract or identification number | 00469681 | | Number of Individuals Covered | 373 | | Insurance policy start date | 2012-08-01 | | Insurance policy end date | 2013-07-31 | | Total amount of commissions paid to insurance broker | USD $32,378 | | Total amount of fees paid to insurance company | USD $12,518 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | 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, VOLUNTARY LIFE, VOLUNTARY 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 $382,180 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $32,378 | | Amount paid for insurance broker fees | 12518 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker organization code? | 3 | | Insurance broker name | TIS INSURANCE SERVICES INC |
|
| COVENTRY HEALTH CARE OF GEORGIA (National Association of Insurance Commissioners NAIC id number: 95282 ) |
| Policy contract number | 6526460000 |
| Policy instance | 1 |
| Insurance contract or identification number | 6526460000 | | Number of Individuals Covered | 586 | | Insurance policy start date | 2012-08-01 | | Insurance policy end date | 2013-07-31 | | Total amount of commissions paid to insurance broker | USD $76,695 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $1,917,379 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $76,695 | | Insurance broker organization code? | 3 | | Insurance broker name | TIS INSURANCE SERVICES INC |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 00469681 |
| Policy instance | 2 |
| Insurance contract or identification number | 00469681 | | Number of Individuals Covered | 420 | | Insurance policy start date | 2011-08-01 | | Insurance policy end date | 2012-07-31 | | Total amount of commissions paid to insurance broker | USD $28,174 | | Total amount of fees paid to insurance company | USD $6,818 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | 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 $325,124 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| COVENTRY HEALTH CARE OF GEORGIA (National Association of Insurance Commissioners NAIC id number: 95282 ) |
| Policy contract number | 6526460000 |
| Policy instance | 1 |
| Insurance contract or identification number | 6526460000 | | Number of Individuals Covered | 541 | | Insurance policy start date | 2011-08-01 | | Insurance policy end date | 2012-07-31 | | Total amount of commissions paid to insurance broker | USD $76,416 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $1,910,388 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 ) |
| Policy contract number | 010-034267 |
| Policy instance | 3 |
| Insurance contract or identification number | 010-034267 | | Number of Individuals Covered | 418 | | Insurance policy start date | 2010-08-01 | | Insurance policy end date | 2011-07-31 | | Total amount of commissions paid to insurance broker | USD $2,109 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $21,094 |
|
| COVENTRY HEALTH CARE OF GEORGIA (National Association of Insurance Commissioners NAIC id number: 95282 ) |
| Policy contract number | 6526460000 |
| Policy instance | 1 |
| Insurance contract or identification number | 6526460000 | | Number of Individuals Covered | 580 | | Insurance policy start date | 2010-08-01 | | Insurance policy end date | 2011-07-31 | | Total amount of commissions paid to insurance broker | USD $77,670 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $1,941,741 |
|
| UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 ) |
| Policy contract number | 5453880 |
| Policy instance | 2 |
| Insurance contract or identification number | 5453880 | | Number of Individuals Covered | 101 | | Insurance policy start date | 2010-08-01 | | Insurance policy end date | 2011-07-31 | | Total amount of commissions paid to insurance broker | USD $8,361 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $83,565 |
|
