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MOUNTVILLE MILLS, INC. EMPLOYEE HEALTH BENEFIT PLAN 401k Plan overview

Plan NameMOUNTVILLE MILLS, INC. EMPLOYEE HEALTH BENEFIT PLAN
Plan identification number 501

MOUNTVILLE MILLS, INC. EMPLOYEE HEALTH BENEFIT PLAN Benefits

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

401k Sponsoring company profile

MOUNTVILLE MILLS, INC. has sponsored the creation of one or more 401k plans.

Company Name:MOUNTVILLE MILLS, INC.
Employer identification number (EIN):580911941
NAIC Classification:314000
NAIC Description: Textile Product Mills

Form 5500 Filing Information

Submission information for form 5500 for 401k plan MOUNTVILLE MILLS, INC. EMPLOYEE HEALTH BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5012021-08-01KENNETH B. EDWARDS2023-02-14
5012020-08-01FRIEDA LILES2022-02-11 FRIEDA LILES2022-02-11
5012019-08-01EMMETT DAVID HART, JR.2021-01-26 EMMETT DAVID HART, JR.2021-01-26
5012018-08-01EMMETT DAVID HART, JR.2020-03-05 EMMETT DAVID HART, JR.2020-03-05
5012017-08-01
5012016-08-01
5012015-08-01
5012014-08-01
5012013-08-01
5012012-08-01TED GLAZIER
5012011-08-01TED GLAZIER
5012010-08-01SUSAN H EKKEBUS
5012009-08-01SUSAN H EKKEBUS

Plan Statistics for MOUNTVILLE MILLS, INC. EMPLOYEE HEALTH BENEFIT PLAN

401k plan membership statisitcs for MOUNTVILLE MILLS, INC. EMPLOYEE HEALTH BENEFIT PLAN

Measure Date Value
2021: MOUNTVILLE MILLS, INC. EMPLOYEE HEALTH BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year2021-08-01576
Total number of active participants reported on line 7a of the Form 55002021-08-01731
Number of retired or separated participants receiving benefits2021-08-010
Number of other retired or separated participants entitled to future benefits2021-08-010
Total of all active and inactive participants2021-08-01731
2020: MOUNTVILLE MILLS, INC. EMPLOYEE HEALTH BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year2020-08-01689
Total number of active participants reported on line 7a of the Form 55002020-08-01576
Total of all active and inactive participants2020-08-01576
2019: MOUNTVILLE MILLS, INC. EMPLOYEE HEALTH BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year2019-08-01809
Total number of active participants reported on line 7a of the Form 55002019-08-01689
Total of all active and inactive participants2019-08-01689
2018: MOUNTVILLE MILLS, INC. EMPLOYEE HEALTH BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year2018-08-01832
Total number of active participants reported on line 7a of the Form 55002018-08-01809
Total of all active and inactive participants2018-08-01809
2017: MOUNTVILLE MILLS, INC. EMPLOYEE HEALTH BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year2017-08-01748
Total number of active participants reported on line 7a of the Form 55002017-08-01832
Total of all active and inactive participants2017-08-01832
2016: MOUNTVILLE MILLS, INC. EMPLOYEE HEALTH BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year2016-08-01711
Total number of active participants reported on line 7a of the Form 55002016-08-01748
Total of all active and inactive participants2016-08-01748
2015: MOUNTVILLE MILLS, INC. EMPLOYEE HEALTH BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year2015-08-01713
Total number of active participants reported on line 7a of the Form 55002015-08-01711
Total of all active and inactive participants2015-08-01711
2014: MOUNTVILLE MILLS, INC. EMPLOYEE HEALTH BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year2014-08-01637
Total number of active participants reported on line 7a of the Form 55002014-08-01713
Total of all active and inactive participants2014-08-01713
2013: MOUNTVILLE MILLS, INC. EMPLOYEE HEALTH BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year2013-08-01545
Total number of active participants reported on line 7a of the Form 55002013-08-01637
Total of all active and inactive participants2013-08-01637
2012: MOUNTVILLE MILLS, INC. EMPLOYEE HEALTH BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year2012-08-01586
Total number of active participants reported on line 7a of the Form 55002012-08-01545
Total of all active and inactive participants2012-08-01545
2011: MOUNTVILLE MILLS, INC. EMPLOYEE HEALTH BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year2011-08-01586
Total number of active participants reported on line 7a of the Form 55002011-08-01586
Total of all active and inactive participants2011-08-01586
2010: MOUNTVILLE MILLS, INC. EMPLOYEE HEALTH BENEFIT PLAN 2010 401k membership
Total participants, beginning-of-year2010-08-01501
Total number of active participants reported on line 7a of the Form 55002010-08-01586
Total of all active and inactive participants2010-08-01586
2009: MOUNTVILLE MILLS, INC. EMPLOYEE HEALTH BENEFIT PLAN 2009 401k membership
Total participants, beginning-of-year2009-08-01515
Total number of active participants reported on line 7a of the Form 55002009-08-01501
Total of all active and inactive participants2009-08-01501

Form 5500 Responses for MOUNTVILLE MILLS, INC. EMPLOYEE HEALTH BENEFIT PLAN

2021: MOUNTVILLE MILLS, INC. EMPLOYEE HEALTH BENEFIT PLAN 2021 form 5500 responses
2021-08-01Type of plan entitySingle employer plan
2021-08-01Plan funding arrangement – General assets of the sponsorYes
2021-08-01Plan benefit arrangement – InsuranceYes
2020: MOUNTVILLE MILLS, INC. EMPLOYEE HEALTH BENEFIT PLAN 2020 form 5500 responses
2020-08-01Type of plan entitySingle employer plan
2020-08-01Plan funding arrangement – General assets of the sponsorYes
2020-08-01Plan benefit arrangement – InsuranceYes
2019: MOUNTVILLE MILLS, INC. EMPLOYEE HEALTH BENEFIT PLAN 2019 form 5500 responses
2019-08-01Type of plan entitySingle employer plan
2019-08-01Plan funding arrangement – General assets of the sponsorYes
2019-08-01Plan benefit arrangement – InsuranceYes
2018: MOUNTVILLE MILLS, INC. EMPLOYEE HEALTH BENEFIT PLAN 2018 form 5500 responses
2018-08-01Type of plan entitySingle employer plan
2018-08-01Plan funding arrangement – General assets of the sponsorYes
2018-08-01Plan benefit arrangement – InsuranceYes
2017: MOUNTVILLE MILLS, INC. EMPLOYEE HEALTH BENEFIT PLAN 2017 form 5500 responses
2017-08-01Type of plan entitySingle employer plan
2017-08-01Plan funding arrangement – General assets of the sponsorYes
2017-08-01Plan benefit arrangement – InsuranceYes
2016: MOUNTVILLE MILLS, INC. EMPLOYEE HEALTH BENEFIT PLAN 2016 form 5500 responses
2016-08-01Type of plan entitySingle employer plan
2016-08-01Plan funding arrangement – General assets of the sponsorYes
2016-08-01Plan benefit arrangement – InsuranceYes
2015: MOUNTVILLE MILLS, INC. EMPLOYEE HEALTH BENEFIT PLAN 2015 form 5500 responses
2015-08-01Type of plan entitySingle employer plan
2015-08-01Plan funding arrangement – General assets of the sponsorYes
2015-08-01Plan benefit arrangement – InsuranceYes
2014: MOUNTVILLE MILLS, INC. EMPLOYEE HEALTH BENEFIT PLAN 2014 form 5500 responses
2014-08-01Type of plan entitySingle employer plan
2014-08-01Plan funding arrangement – General assets of the sponsorYes
2014-08-01Plan benefit arrangement – InsuranceYes
2013: MOUNTVILLE MILLS, INC. EMPLOYEE HEALTH BENEFIT PLAN 2013 form 5500 responses
2013-08-01Type of plan entitySingle employer plan
2013-08-01Plan funding arrangement – General assets of the sponsorYes
2013-08-01Plan benefit arrangement – InsuranceYes
2012: MOUNTVILLE MILLS, INC. EMPLOYEE HEALTH BENEFIT PLAN 2012 form 5500 responses
2012-08-01Type of plan entitySingle employer plan
2012-08-01Plan funding arrangement – General assets of the sponsorYes
2012-08-01Plan benefit arrangement – InsuranceYes
2011: MOUNTVILLE MILLS, INC. EMPLOYEE HEALTH BENEFIT PLAN 2011 form 5500 responses
2011-08-01Type of plan entitySingle employer plan
2011-08-01Plan funding arrangement – General assets of the sponsorYes
2011-08-01Plan benefit arrangement – InsuranceYes
2010: MOUNTVILLE MILLS, INC. EMPLOYEE HEALTH BENEFIT PLAN 2010 form 5500 responses
2010-08-01Type of plan entitySingle employer plan
2010-08-01Plan funding arrangement – General assets of the sponsorYes
2010-08-01Plan benefit arrangement – InsuranceYes
2009: MOUNTVILLE MILLS, INC. EMPLOYEE HEALTH BENEFIT PLAN 2009 form 5500 responses
2009-08-01Type of plan entitySingle employer plan
2009-08-01This submission is the final filingNo
2009-08-01Plan funding arrangement – General assets of the sponsorYes
2009-08-01Plan benefit arrangement – InsuranceYes

Insurance Providers Used on plan

BLUE CROSS BLUE SHIELD OF GEORGIA INC. (G0386) (National Association of Insurance Commissioners NAIC id number: 96962 )
Policy contract numberGA7222
Policy instance 4
Insurance contract or identification numberGA7222
Number of Individuals Covered691
Insurance policy start date2021-06-01
Insurance policy end date2022-05-31
Total amount of commissions paid to insurance brokerUSD $65,266
Total amount of fees paid to insurance companyUSD $1,332
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $3,903,512
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $65,266
Amount paid for insurance broker fees1332
Additional information about fees paid to insurance brokerINCENTIVES, EDUCATION, AND TRAINING
Insurance broker organization code?3
GREATER GEORGIA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 97217 )
Policy contract numberGA1940
Policy instance 3
Insurance contract or identification numberGA1940
Number of Individuals Covered698
Insurance policy start date2021-06-01
Insurance policy end date2022-05-31
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $217,173
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
BLUE CROSS AND BLUE SHIELD OF GEORGIA, INC/ (G0385) (National Association of Insurance Commissioners NAIC id number: 54801 )
Policy contract numberGA7222
Policy instance 2
Insurance contract or identification numberGA7222
Number of Individuals Covered731
Insurance policy start date2021-06-01
Insurance policy end date2022-05-31
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $219,886
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 numberABL656549
Policy instance 1
Insurance contract or identification numberABL656549
Number of Individuals Covered39
Insurance policy start date2020-12-10
Insurance policy end date2021-12-10
Total amount of commissions paid to insurance brokerUSD $722
Other welfare benefits providedACCIDENTAL DEATH
Welfare Benefit Premiums Paid to CarrierUSD $3,611
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $722
Additional information about fees paid to insurance brokerSALES AND SERVICE
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberABL656549
Policy instance 1
Insurance contract or identification numberABL656549
Number of Individuals Covered44
Insurance policy start date2019-12-10
Insurance policy end date2020-12-10
Total amount of commissions paid to insurance brokerUSD $815
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $4,074
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $815
Insurance broker organization code?3
BLUE CROSS AND BLUE SHIELD OF GEORGIA, INC/ (G0385) (National Association of Insurance Commissioners NAIC id number: 54801 )
Policy contract numberGA7222
Policy instance 2
Insurance contract or identification numberGA7222
Number of Individuals Covered576
Insurance policy start date2020-06-01
Insurance policy end date2021-05-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $238,249
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
GREATER GEORGIA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 97217 )
Policy contract numberGA1940
Policy instance 3
Insurance contract or identification numberGA1940
Number of Individuals Covered535
Insurance policy start date2020-06-01
Insurance policy end date2021-05-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $208,164
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 numberGA7222
Policy instance 4
Insurance contract or identification numberGA7222
Number of Individuals Covered560
Insurance policy start date2020-06-01
Insurance policy end date2021-05-31
Total amount of commissions paid to insurance brokerUSD $69,249
Total amount of fees paid to insurance companyUSD $3,186
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $3,690,812
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $51,100
Amount paid for insurance broker fees3186
Additional information about fees paid to insurance brokerOVERRIDES, BONUS PAYMENTS AND OTHER COMPENSATION
Insurance broker organization code?3
BLUE CROSS AND BLUE SHIELD OF GEORGIA, INC/ (G0385) (National Association of Insurance Commissioners NAIC id number: 54801 )
Policy contract numberGA7222
Policy instance 2
Insurance contract or identification numberGA7222
Number of Individuals Covered676
Insurance policy start date2019-05-01
Insurance policy end date2020-05-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $315,672
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 numberABL656549
Policy instance 1
Insurance contract or identification numberABL656549
Number of Individuals Covered46
Insurance policy start date2018-12-10
Insurance policy end date2019-12-10
Total amount of commissions paid to insurance brokerUSD $815
Total amount of fees paid to insurance companyUSD $59
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $4,074
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $815
Amount paid for insurance broker fees59
Additional information about fees paid to insurance brokerOVERRIDE
Insurance broker organization code?3
GREATER GEORGIA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 97217 )
Policy contract numberGA1940
Policy instance 3
Insurance contract or identification numberGA1940
Number of Individuals Covered676
Insurance policy start date2019-05-01
Insurance policy end date2020-05-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $249,263
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 numberGA7222
Policy instance 4
Insurance contract or identification numberGA7222
Number of Individuals Covered689
Insurance policy start date2019-05-01
Insurance policy end date2020-05-31
Total amount of commissions paid to insurance brokerUSD $102,839
Total amount of fees paid to insurance companyUSD $175
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $4,717,765
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $72,179
Amount paid for insurance broker fees175
Additional information about fees paid to insurance brokerOVERRIDES
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberABL656549
Policy instance 1
Insurance contract or identification numberABL656549
Number of Individuals Covered30
Insurance policy start date2017-12-10
Insurance policy end date2018-12-10
Total amount of commissions paid to insurance brokerUSD $784
Total amount of fees paid to insurance companyUSD $83
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $3,921
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $784
Amount paid for insurance broker fees83
Additional information about fees paid to insurance brokerOVERRIDE
Insurance broker organization code?3
BLUE CROSS AND BLUE SHIELD OF GEORGIA, INC/ (G0385) (National Association of Insurance Commissioners NAIC id number: 54801 )
Policy contract numberGA7222
Policy instance 2
Insurance contract or identification numberGA7222
Number of Individuals Covered671
Insurance policy start date2018-05-01
Insurance policy end date2019-04-30
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $256,003
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
GREATER GEORGIA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 97217 )
Policy contract numberGA1940
Policy instance 3
Insurance contract or identification numberGA1940
Number of Individuals Covered809
Insurance policy start date2018-05-01
Insurance policy end date2019-04-30
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $234,086
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 numberGA7222
Policy instance 4
Insurance contract or identification numberGA7222
Number of Individuals Covered715
Insurance policy start date2018-05-01
Insurance policy end date2019-04-30
Total amount of commissions paid to insurance brokerUSD $103,640
Total amount of fees paid to insurance companyUSD $283
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $4,307,656
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $51,172
Amount paid for insurance broker fees283
Additional information about fees paid to insurance brokerOVERIDES
Insurance broker organization code?3
BLUE CROSS BLUE SHIELD OF GEORGIA INC. (G0386) (National Association of Insurance Commissioners NAIC id number: 96962 )
Policy contract numberGA7222
Policy instance 4
Insurance contract or identification numberGA7222
Number of Individuals Covered727
Insurance policy start date2017-05-01
Insurance policy end date2018-04-30
Total amount of commissions paid to insurance brokerUSD $106,138
Total amount of fees paid to insurance companyUSD $10,540
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $4,218,053
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
GREATER GEORGIA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 97217 )
Policy contract numberGA1940
Policy instance 3
Insurance contract or identification numberGA1940
Number of Individuals Covered832
Insurance policy start date2017-05-01
Insurance policy end date2018-04-30
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $232,127
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
BLUE CROSS AND BLUE SHIELD OF GEORGIA, INC/ (G0385) (National Association of Insurance Commissioners NAIC id number: 54801 )
Policy contract numberGA7222
Policy instance 2
Insurance contract or identification numberGA7222
Number of Individuals Covered722
Insurance policy start date2017-05-01
Insurance policy end date2018-04-30
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $259,152
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 numberABL656549
Policy instance 1
Insurance contract or identification numberABL656549
Number of Individuals Covered30
Insurance policy start date2016-12-10
Insurance policy end date2017-12-10
Total amount of commissions paid to insurance brokerUSD $784
Total amount of fees paid to insurance companyUSD $83
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $3,921
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 numberGA7222
Policy instance 4
Insurance contract or identification numberGA7222
Number of Individuals Covered711
Insurance policy start date2015-05-01
Insurance policy end date2016-04-30
Total amount of commissions paid to insurance brokerUSD $121,777
Total amount of fees paid to insurance companyUSD $12,978
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $3,735,542
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $91,719
Amount paid for insurance broker fees12978
Additional information about fees paid to insurance brokerINCENTIVES, EDUCATION, COMMUNICATION AND TRAINING
Insurance broker organization code?3
Insurance broker namePETER P ROBINSON INSURANCE AGENCY
BLUE CROSS AND BLUE SHIELD OF GEORGIA, INC/ (G0385) (National Association of Insurance Commissioners NAIC id number: 54801 )
Policy contract numberGA7222
Policy instance 2
Insurance contract or identification numberGA7222
Number of Individuals Covered678
Insurance policy start date2015-05-01
Insurance policy end date2016-04-30
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $249,536
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 numberABL656549
Policy instance 1
Insurance contract or identification numberABL656549
Number of Individuals Covered30
Insurance policy start date2014-12-10
Insurance policy end date2015-12-10
Total amount of commissions paid to insurance brokerUSD $794
Total amount of fees paid to insurance companyUSD $59
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $3,972
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $794
Amount paid for insurance broker fees59
Additional information about fees paid to insurance brokerMISCELLANEOUS SERVICES
Insurance broker organization code?3
Insurance broker nameJ SMITH LANIER & CO
GREATER GEORGIA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 97217 )
Policy contract numberGA1940
Policy instance 3
Insurance contract or identification numberGA1940
Number of Individuals Covered0
Insurance policy start date2015-05-01
Insurance policy end date2016-04-30
Total amount of commissions paid to insurance brokerUSD $2,122
Total amount of fees paid to insurance companyUSD $5,056
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $177,317
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,122
Amount paid for insurance broker fees5056
Additional information about fees paid to insurance brokerINCENTIVES, EDUCATION, COMMUNICATION AND TRAINING
Insurance broker organization code?3
Insurance broker nameJ SMITH LANIER & CO
BLUE CROSS AND BLUE SHIELD OF GEORGIA, INC/ (G0385) (National Association of Insurance Commissioners NAIC id number: 54801 )
Policy contract numberGA7222
Policy instance 2
Insurance contract or identification numberGA7222
Number of Individuals Covered612
Insurance policy start date2014-05-01
Insurance policy end date2015-04-30
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $236,760
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
GREATER GEORGIA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 97217 )
Policy contract numberGA1940
Policy instance 3
Insurance contract or identification numberGA1940
Number of Individuals Covered517
Insurance policy start date2014-05-01
Insurance policy end date2015-04-30
Total amount of commissions paid to insurance brokerUSD $6,139
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $162,192
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6,139
Insurance broker organization code?3
Insurance broker nameJ SMITH LANIER & CO
BLUE CROSS BLUE SHIELD OF GEORGIA INC. (G0386) (National Association of Insurance Commissioners NAIC id number: 96962 )
Policy contract number1044982000
Policy instance 5
Insurance contract or identification number1044982000
Number of Individuals Covered0
Insurance policy start date2014-05-01
Insurance policy end date2015-04-30
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,503
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
BLUE CROSS AND BLUE SHIELD OF GEORGIA, INC/ (G0385) (National Association of Insurance Commissioners NAIC id number: 54801 )
Policy contract number1044982000
Policy instance 6
Insurance contract or identification number1044982000
Number of Individuals Covered0
Insurance policy start date2014-05-01
Insurance policy end date2015-04-30
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $86
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 numberGA7222
Policy instance 4
Insurance contract or identification numberGA7222
Number of Individuals Covered713
Insurance policy start date2014-05-01
Insurance policy end date2015-04-30
Total amount of commissions paid to insurance brokerUSD $144,228
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $3,059,075
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $109,335
Insurance broker organization code?3
Insurance broker namePETER P ROBINSON INSURANCE AGENCY
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberABL656549
Policy instance 1
Insurance contract or identification numberABL656549
Number of Individuals Covered30
Insurance policy start date2013-12-10
Insurance policy end date2014-12-10
Total amount of commissions paid to insurance brokerUSD $745
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $3,724
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $745
Insurance broker organization code?3
Insurance broker nameJ SMITH LANIER & CO
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberABL656549
Policy instance 1
Insurance contract or identification numberABL656549
Insurance policy start date2012-12-10
Insurance policy end date2013-12-10
Total amount of commissions paid to insurance brokerUSD $359
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $1,796
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $359
Insurance broker organization code?3
Insurance broker nameJ SMITH LANIER & CO
BLUE CROSS BLUE SHIELD OF GEORGIA INC. (G0386) (National Association of Insurance Commissioners NAIC id number: 96962 )
Policy contract numberGA7222
Policy instance 4
Insurance contract or identification numberGA7222
Number of Individuals Covered637
Insurance policy start date2013-05-01
Insurance policy end date2014-04-30
Total amount of commissions paid to insurance brokerUSD $121,355
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $2,740,762
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $91,937
Insurance broker organization code?3
Insurance broker namePETER P ROBINSON INSURANCE AGENCY
GREATER GEORGIA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 97217 )
Policy contract numberGA1940
Policy instance 3
Insurance contract or identification numberGA1940
Number of Individuals Covered477
Insurance policy start date2013-05-01
Insurance policy end date2014-04-30
Total amount of commissions paid to insurance brokerUSD $13,533
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $131,826
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $13,533
Insurance broker organization code?3
Insurance broker nameJ SMITH LANIER & CO
BLUE CROSS AND BLUE SHIELD OF GEORGIA, INC/ (G0385) (National Association of Insurance Commissioners NAIC id number: 54801 )
Policy contract numberGA7222
Policy instance 2
Insurance contract or identification numberGA7222
Number of Individuals Covered558
Insurance policy start date2013-05-01
Insurance policy end date2014-04-30
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $222,949
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 numberABL656549
Policy instance 1
Insurance contract or identification numberABL656549
Number of Individuals Covered30
Insurance policy start date2011-12-10
Insurance policy end date2012-12-10
Total amount of commissions paid to insurance brokerUSD $359
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $1,796
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $359
Insurance broker organization code?3
Insurance broker nameJ SMITH LANIER & CO
GREATER GEORGIA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 97217 )
Policy contract numberGA1940
Policy instance 3
Insurance contract or identification numberGA1940
Number of Individuals Covered506
Insurance policy start date2012-05-01
Insurance policy end date2013-04-30
Total amount of commissions paid to insurance brokerUSD $14,430
Total amount of fees paid to insurance companyUSD $2,544
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $113,010
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $14,430
Amount paid for insurance broker fees2544
Additional information about fees paid to insurance brokerINCENTIVES, EDUCATION, COMMUNICATION AND TRAINING
Insurance broker organization code?3
Insurance broker nameJ SMITH LANIER & CO
BLUE CROSS AND BLUE SHIELD OF GEORGIA, INC/ (G0385) (National Association of Insurance Commissioners NAIC id number: 54801 )
Policy contract number1044982000
Policy instance 2
Insurance contract or identification number1044982000
Number of Individuals Covered545
Insurance policy start date2012-05-01
Insurance policy end date2013-04-30
Total amount of commissions paid to insurance brokerUSD $144,484
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $2,681,592
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $80,376
Insurance broker organization code?3
Insurance broker namePETER ROBINSON INSURANCE AGENCY INC
BLUE CROSS AND BLUE SHIELD OF GEORGIA, INC/ (G0385) (National Association of Insurance Commissioners NAIC id number: 54801 )
Policy contract number1044982000
Policy instance 2
Insurance contract or identification number1044982000
Number of Individuals Covered586
Insurance policy start date2011-05-01
Insurance policy end date2012-04-30
Total amount of commissions paid to insurance brokerUSD $141,883
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $2,504,011
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
GREATER GEORGIA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 97217 )
Policy contract numberGA1940
Policy instance 3
Insurance contract or identification numberGA1940
Number of Individuals Covered545
Insurance policy start date2011-05-01
Insurance policy end date2012-04-30
Total amount of commissions paid to insurance brokerUSD $16,288
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $160,112
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 numberABL656549
Policy instance 1
Insurance contract or identification numberABL656549
Number of Individuals Covered30
Insurance policy start date2010-12-10
Insurance policy end date2011-12-10
Total amount of commissions paid to insurance brokerUSD $359
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $1,796
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 numberABL656549
Policy instance 1
Insurance contract or identification numberABL656549
Number of Individuals Covered30
Insurance policy start date2009-12-10
Insurance policy end date2010-12-10
Total amount of commissions paid to insurance brokerUSD $359
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $1,795
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
BLUE CROSS AND BLUE SHIELD OF GEORGIA, INC/ (G0385) (National Association of Insurance Commissioners NAIC id number: 54801 )
Policy contract number1044982000
Policy instance 2
Insurance contract or identification number1044982000
Number of Individuals Covered586
Insurance policy start date2010-05-01
Insurance policy end date2011-04-30
Total amount of commissions paid to insurance brokerUSD $124,373
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $2,220,259
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
GREATER GEORGIA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 97217 )
Policy contract numberGA1940
Policy instance 3
Insurance contract or identification numberGA1940
Number of Individuals Covered512
Insurance policy start date2010-05-01
Insurance policy end date2011-04-30
Total amount of commissions paid to insurance brokerUSD $8,651
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $73,579
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No

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