PEACH STATE TRUCK CENTERS, LLC has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan PEACH STATE TRUCK CENTERS, LLC WELFARE PLAN
| Measure | Date | Value |
|---|
| 2022: PEACH STATE TRUCK CENTERS, LLC WELFARE PLAN 2022 401k membership |
|---|
| Total participants, beginning-of-year | 2022-09-01 | 686 |
| Total number of active participants reported on line 7a of the Form 5500 | 2022-09-01 | 738 |
| Number of retired or separated participants receiving benefits | 2022-09-01 | 2 |
| Number of other retired or separated participants entitled to future benefits | 2022-09-01 | 7 |
| Total of all active and inactive participants | 2022-09-01 | 747 |
| 2021: PEACH STATE TRUCK CENTERS, LLC WELFARE PLAN 2021 401k membership |
|---|
| Total participants, beginning-of-year | 2021-09-01 | 645 |
| Total number of active participants reported on line 7a of the Form 5500 | 2021-09-01 | 717 |
| Number of retired or separated participants receiving benefits | 2021-09-01 | 1 |
| Number of other retired or separated participants entitled to future benefits | 2021-09-01 | 9 |
| Total of all active and inactive participants | 2021-09-01 | 727 |
| 2020: PEACH STATE TRUCK CENTERS, LLC WELFARE PLAN 2020 401k membership |
|---|
| Total participants, beginning-of-year | 2020-09-01 | 597 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-09-01 | 643 |
| Number of retired or separated participants receiving benefits | 2020-09-01 | 2 |
| Number of other retired or separated participants entitled to future benefits | 2020-09-01 | 0 |
| Total of all active and inactive participants | 2020-09-01 | 645 |
| 2019: PEACH STATE TRUCK CENTERS, LLC WELFARE PLAN 2019 401k membership |
|---|
| Total participants, beginning-of-year | 2019-09-01 | 625 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-09-01 | 587 |
| Number of retired or separated participants receiving benefits | 2019-09-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2019-09-01 | 10 |
| Total of all active and inactive participants | 2019-09-01 | 597 |
| 2018: PEACH STATE TRUCK CENTERS, LLC WELFARE PLAN 2018 401k membership |
|---|
| Total participants, beginning-of-year | 2018-09-01 | 610 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-09-01 | 625 |
| Number of retired or separated participants receiving benefits | 2018-09-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2018-09-01 | 0 |
| Total of all active and inactive participants | 2018-09-01 | 625 |
| 2017: PEACH STATE TRUCK CENTERS, LLC WELFARE PLAN 2017 401k membership |
|---|
| Total participants, beginning-of-year | 2017-09-01 | 548 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-09-01 | 578 |
| Number of retired or separated participants receiving benefits | 2017-09-01 | 3 |
| Number of other retired or separated participants entitled to future benefits | 2017-09-01 | 5 |
| Total of all active and inactive participants | 2017-09-01 | 586 |
| 2016: PEACH STATE TRUCK CENTERS, LLC WELFARE PLAN 2016 401k membership |
|---|
| Total participants, beginning-of-year | 2016-09-01 | 545 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-09-01 | 542 |
| Number of retired or separated participants receiving benefits | 2016-09-01 | 1 |
| Number of other retired or separated participants entitled to future benefits | 2016-09-01 | 0 |
| Total of all active and inactive participants | 2016-09-01 | 543 |
| 2015: PEACH STATE TRUCK CENTERS, LLC WELFARE PLAN 2015 401k membership |
|---|
| Total participants, beginning-of-year | 2015-09-01 | 239 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-09-01 | 538 |
| Number of retired or separated participants receiving benefits | 2015-09-01 | 7 |
| Number of other retired or separated participants entitled to future benefits | 2015-09-01 | 0 |
| Total of all active and inactive participants | 2015-09-01 | 545 |
| 2014: PEACH STATE TRUCK CENTERS, LLC WELFARE PLAN 2014 401k membership |
|---|
| Total participants, beginning-of-year | 2014-09-01 | 422 |
| Total number of active participants reported on line 7a of the Form 5500 | 2014-09-01 | 239 |
| Number of retired or separated participants receiving benefits | 2014-09-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2014-09-01 | 0 |
| Total of all active and inactive participants | 2014-09-01 | 239 |
| 2013: PEACH STATE TRUCK CENTERS, LLC WELFARE PLAN 2013 401k membership |
|---|
| Total participants, beginning-of-year | 2013-09-01 | 352 |
| Total number of active participants reported on line 7a of the Form 5500 | 2013-09-01 | 422 |
| Total of all active and inactive participants | 2013-09-01 | 422 |
| 2012: PEACH STATE TRUCK CENTERS, LLC WELFARE PLAN 2012 401k membership |
|---|
| Total participants, beginning-of-year | 2012-09-01 | 352 |
| Total number of active participants reported on line 7a of the Form 5500 | 2012-09-01 | 351 |
| Number of retired or separated participants receiving benefits | 2012-09-01 | 1 |
| Total of all active and inactive participants | 2012-09-01 | 352 |
| 2011: PEACH STATE TRUCK CENTERS, LLC WELFARE PLAN 2011 401k membership |
|---|
| Total participants, beginning-of-year | 2011-09-01 | 341 |
| Total number of active participants reported on line 7a of the Form 5500 | 2011-09-01 | 352 |
| Total of all active and inactive participants | 2011-09-01 | 352 |
| 2009: PEACH STATE TRUCK CENTERS, LLC WELFARE PLAN 2009 401k membership |
|---|
| Total participants, beginning-of-year | 2009-09-01 | 286 |
| Total number of active participants reported on line 7a of the Form 5500 | 2009-09-01 | 249 |
| Number of retired or separated participants receiving benefits | 2009-09-01 | 9 |
| Number of other retired or separated participants entitled to future benefits | 2009-09-01 | 0 |
| Total of all active and inactive participants | 2009-09-01 | 258 |
| 2008: PEACH STATE TRUCK CENTERS, LLC WELFARE PLAN 2008 401k membership |
|---|
| Total participants, beginning-of-year | 2008-09-01 | 147 |
| Total number of active participants reported on line 7a of the Form 5500 | 2008-09-01 | 163 |
| Number of retired or separated participants receiving benefits | 2008-09-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2008-09-01 | 0 |
| Total of all active and inactive participants | 2008-09-01 | 163 |
| 2005: PEACH STATE TRUCK CENTERS, LLC WELFARE PLAN 2005 401k membership |
|---|
| Total participants, beginning-of-year | 2005-12-01 | 100 |
| Total number of active participants reported on line 7a of the Form 5500 | 2005-12-01 | 149 |
| Number of retired or separated participants receiving benefits | 2005-12-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2005-12-01 | 0 |
| Total of all active and inactive participants | 2005-12-01 | 149 |
| 2022: PEACH STATE TRUCK CENTERS, LLC WELFARE PLAN 2022 form 5500 responses |
|---|
| 2022-09-01 | Type of plan entity | Single employer plan |
| 2022-09-01 | Submission has been amended | No |
| 2022-09-01 | This submission is the final filing | No |
| 2022-09-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2022-09-01 | Plan is a collectively bargained plan | No |
| 2022-09-01 | Plan funding arrangement – Insurance | Yes |
| 2022-09-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2022-09-01 | Plan benefit arrangement – Insurance | Yes |
| 2022-09-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2021: PEACH STATE TRUCK CENTERS, LLC WELFARE PLAN 2021 form 5500 responses |
|---|
| 2021-09-01 | Type of plan entity | Single employer plan |
| 2021-09-01 | Submission has been amended | No |
| 2021-09-01 | This submission is the final filing | No |
| 2021-09-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2021-09-01 | Plan is a collectively bargained plan | No |
| 2021-09-01 | Plan funding arrangement – Insurance | Yes |
| 2021-09-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2021-09-01 | Plan benefit arrangement – Insurance | Yes |
| 2021-09-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2020: PEACH STATE TRUCK CENTERS, LLC WELFARE PLAN 2020 form 5500 responses |
|---|
| 2020-09-01 | Type of plan entity | Single employer plan |
| 2020-09-01 | Submission has been amended | No |
| 2020-09-01 | This submission is the final filing | No |
| 2020-09-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2020-09-01 | Plan is a collectively bargained plan | No |
| 2020-09-01 | Plan funding arrangement – Insurance | Yes |
| 2020-09-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2020-09-01 | Plan benefit arrangement – Insurance | Yes |
| 2020-09-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2019: PEACH STATE TRUCK CENTERS, LLC WELFARE PLAN 2019 form 5500 responses |
|---|
| 2019-09-01 | Type of plan entity | Single employer plan |
| 2019-09-01 | Submission has been amended | No |
| 2019-09-01 | This submission is the final filing | No |
| 2019-09-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2019-09-01 | Plan is a collectively bargained plan | No |
| 2019-09-01 | Plan funding arrangement – Insurance | Yes |
| 2019-09-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2019-09-01 | Plan benefit arrangement – Insurance | Yes |
| 2019-09-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2018: PEACH STATE TRUCK CENTERS, LLC WELFARE PLAN 2018 form 5500 responses |
|---|
| 2018-09-01 | Type of plan entity | Single employer plan |
| 2018-09-01 | Submission has been amended | No |
| 2018-09-01 | This submission is the final filing | No |
| 2018-09-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2018-09-01 | Plan is a collectively bargained plan | No |
| 2018-09-01 | Plan funding arrangement – Insurance | Yes |
| 2018-09-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2018-09-01 | Plan benefit arrangement – Insurance | Yes |
| 2018-09-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2017: PEACH STATE TRUCK CENTERS, LLC WELFARE PLAN 2017 form 5500 responses |
|---|
| 2017-09-01 | Type of plan entity | Single employer plan |
| 2017-09-01 | Submission has been amended | No |
| 2017-09-01 | This submission is the final filing | No |
| 2017-09-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2017-09-01 | Plan is a collectively bargained plan | No |
| 2017-09-01 | Plan funding arrangement – Insurance | Yes |
| 2017-09-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2017-09-01 | Plan benefit arrangement – Insurance | Yes |
| 2017-09-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2016: PEACH STATE TRUCK CENTERS, LLC WELFARE PLAN 2016 form 5500 responses |
|---|
| 2016-09-01 | Type of plan entity | Single employer plan |
| 2016-09-01 | Plan funding arrangement – Insurance | Yes |
| 2016-09-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2016-09-01 | Plan benefit arrangement – Insurance | Yes |
| 2016-09-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2015: PEACH STATE TRUCK CENTERS, LLC WELFARE PLAN 2015 form 5500 responses |
|---|
| 2015-09-01 | Type of plan entity | Single employer plan |
| 2015-09-01 | Plan funding arrangement – Insurance | Yes |
| 2015-09-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2015-09-01 | Plan benefit arrangement – Insurance | Yes |
| 2015-09-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2014: PEACH STATE TRUCK CENTERS, LLC WELFARE PLAN 2014 form 5500 responses |
|---|
| 2014-09-01 | Type of plan entity | Single employer plan |
| 2014-09-01 | Plan funding arrangement – Insurance | Yes |
| 2014-09-01 | Plan benefit arrangement – Insurance | Yes |
| 2013: PEACH STATE TRUCK CENTERS, LLC WELFARE PLAN 2013 form 5500 responses |
|---|
| 2013-09-01 | Type of plan entity | Single employer plan |
| 2013-09-01 | Submission has been amended | No |
| 2013-09-01 | This submission is the final filing | No |
| 2013-09-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2013-09-01 | Plan is a collectively bargained plan | No |
| 2013-09-01 | Plan funding arrangement – Insurance | Yes |
| 2013-09-01 | Plan benefit arrangement – Insurance | Yes |
| 2012: PEACH STATE TRUCK CENTERS, LLC WELFARE PLAN 2012 form 5500 responses |
|---|
| 2012-09-01 | Type of plan entity | Single employer plan |
| 2012-09-01 | Submission has been amended | No |
| 2012-09-01 | This submission is the final filing | No |
| 2012-09-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2012-09-01 | Plan is a collectively bargained plan | No |
| 2012-09-01 | Plan funding arrangement – Insurance | Yes |
| 2012-09-01 | Plan benefit arrangement – Insurance | Yes |
| 2011: PEACH STATE TRUCK CENTERS, LLC WELFARE PLAN 2011 form 5500 responses |
|---|
| 2011-09-01 | Type of plan entity | Single employer plan |
| 2011-09-01 | Submission has been amended | No |
| 2011-09-01 | This submission is the final filing | No |
| 2011-09-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2011-09-01 | Plan is a collectively bargained plan | No |
| 2011-09-01 | Plan funding arrangement – Insurance | Yes |
| 2011-09-01 | Plan benefit arrangement – Insurance | Yes |
| 2009: PEACH STATE TRUCK CENTERS, LLC WELFARE PLAN 2009 form 5500 responses |
|---|
| 2009-09-01 | Type of plan entity | Single employer plan |
| 2009-09-01 | Submission has been amended | No |
| 2009-09-01 | This submission is the final filing | No |
| 2009-09-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2009-09-01 | Plan is a collectively bargained plan | No |
| 2009-09-01 | Plan funding arrangement – Insurance | Yes |
| 2009-09-01 | Plan benefit arrangement – Insurance | Yes |
| 2008: PEACH STATE TRUCK CENTERS, LLC WELFARE PLAN 2008 form 5500 responses |
|---|
| 2008-09-01 | Type of plan entity | Single employer plan |
| 2008-09-01 | Submission has been amended | No |
| 2008-09-01 | This submission is the final filing | No |
| 2008-09-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2008-09-01 | Plan is a collectively bargained plan | No |
| 2008-09-01 | Plan funding arrangement – Insurance | Yes |
| 2008-09-01 | Plan benefit arrangement – Insurance | Yes |
| 2005: PEACH STATE TRUCK CENTERS, LLC WELFARE PLAN 2005 form 5500 responses |
|---|
| 2005-12-01 | Type of plan entity | Single employer plan |
| 2005-12-01 | First time form 5500 has been submitted | Yes |
| 2005-12-01 | Submission has been amended | No |
| 2005-12-01 | This submission is the final filing | No |
| 2005-12-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2005-12-01 | Plan is a collectively bargained plan | No |
| 2005-12-01 | Plan funding arrangement – Insurance | Yes |
| 2005-12-01 | Plan benefit arrangement – Insurance | Yes |
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 98857081001 |
| Policy instance | 2 |
| Insurance contract or identification number | 98857081001 | | Number of Individuals Covered | 752 | | Insurance policy start date | 2022-09-01 | | Insurance policy end date | 2023-08-31 | | Total amount of commissions paid to insurance broker | USD $5,063 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $51,033 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,063 | | Insurance broker organization code? | 3 |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 00490804 |
| Policy instance | 1 |
| Insurance contract or identification number | 00490804 | | Number of Individuals Covered | 719 | | Insurance policy start date | 2022-09-01 | | Insurance policy end date | 2023-08-31 | | Total amount of commissions paid to insurance broker | USD $87,324 | | Total amount of fees paid to insurance company | USD $6,600 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | 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 | AD&D, VOLUNTARY LIFE, CRITICAL ILLNESS, ACCIDENT | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $724,462 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $87,324 | | Amount paid for insurance broker fees | 6600 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker organization code? | 3 |
|
| COMPANION LIFE (National Association of Insurance Commissioners NAIC id number: 77828 ) |
| Policy contract number | CLI 51, 031 |
| Policy instance | 3 |
| Insurance contract or identification number | CLI 51, 031 | | Number of Individuals Covered | 443 | | Insurance policy start date | 2022-09-01 | | Insurance policy end date | 2023-08-31 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | 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 $473,294 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 98857081001 |
| Policy instance | 2 |
| Insurance contract or identification number | 98857081001 | | Number of Individuals Covered | 1374 | | Insurance policy start date | 2021-09-01 | | Insurance policy end date | 2022-08-31 | | Total amount of commissions paid to insurance broker | USD $5,076 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $47,215 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,076 | | Insurance broker organization code? | 3 |
|
| NATIONWIDE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 66869 ) |
| Policy contract number | NWES0013602 |
| Policy instance | 3 |
| Insurance contract or identification number | NWES0013602 | | Number of Individuals Covered | 415 | | Insurance policy start date | 2021-09-01 | | Insurance policy end date | 2022-08-31 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | 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 $393,815 | | 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 | 00490804 |
| Policy instance | 1 |
| Insurance contract or identification number | 00490804 | | Number of Individuals Covered | 666 | | Insurance policy start date | 2021-09-01 | | Insurance policy end date | 2022-08-31 | | Total amount of commissions paid to insurance broker | USD $57,538 | | Total amount of fees paid to insurance company | USD $3,382 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | 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 | AD&D, VOLUNTARY LIFE | | 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 $530,128 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $57,538 | | Amount paid for insurance broker fees | 3382 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker organization code? | 3 |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 00490804 |
| Policy instance | 1 |
| Insurance contract or identification number | 00490804 | | Number of Individuals Covered | 643 | | Insurance policy start date | 2020-09-01 | | Insurance policy end date | 2021-08-31 | | Total amount of commissions paid to insurance broker | USD $60,014 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | 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 | AD&D, VOLUNTARY LIFE | | 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 $550,026 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $60,014 | | Insurance broker organization code? | 3 |
|
| NATIONWIDE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 66869 ) |
| Policy contract number | NWES0013601 |
| Policy instance | 3 |
| Insurance contract or identification number | NWES0013601 | | Number of Individuals Covered | 410 | | Insurance policy start date | 2020-09-01 | | Insurance policy end date | 2021-08-31 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | 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 $355,736 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 98857081001 |
| Policy instance | 2 |
| Insurance contract or identification number | 98857081001 | | Number of Individuals Covered | 631 | | Insurance policy start date | 2020-09-01 | | Insurance policy end date | 2021-08-31 | | Total amount of commissions paid to insurance broker | USD $4,359 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $44,120 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,359 | | Insurance broker organization code? | 3 |
|
| NATIONWIDE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 66869 ) |
| Policy contract number | NWES0013600 |
| Policy instance | 3 |
| Insurance contract or identification number | NWES0013600 | | Number of Individuals Covered | 398 | | Insurance policy start date | 2019-09-01 | | Insurance policy end date | 2020-08-31 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | 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 $315,094 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 98857081001 |
| Policy instance | 2 |
| Insurance contract or identification number | 98857081001 | | Number of Individuals Covered | 570 | | Insurance policy start date | 2019-09-01 | | Insurance policy end date | 2020-08-31 | | Total amount of commissions paid to insurance broker | USD $4,061 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $40,682 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,061 | | Insurance broker organization code? | 3 |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 00490804 |
| Policy instance | 1 |
| Insurance contract or identification number | 00490804 | | Number of Individuals Covered | 588 | | Insurance policy start date | 2019-09-01 | | Insurance policy end date | 2020-08-31 | | Total amount of commissions paid to insurance broker | USD $56,886 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | 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 | AD&D, OPTIONAL LIFE | | 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 $520,341 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $56,886 | | Insurance broker organization code? | 3 |
|
| LIBERTY INSURANCE UNDERWRITERS, INC. (National Association of Insurance Commissioners NAIC id number: ) |
| Policy contract number | TRU000143-01 |
| Policy instance | 3 |
| Insurance contract or identification number | TRU000143-01 | | Number of Individuals Covered | 385 | | Insurance policy start date | 2018-09-01 | | Insurance policy end date | 2019-08-31 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | 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 $331,400 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 98857081001 |
| Policy instance | 2 |
| Insurance contract or identification number | 98857081001 | | Number of Individuals Covered | 543 | | Insurance policy start date | 2018-09-01 | | Insurance policy end date | 2019-08-31 | | Total amount of commissions paid to insurance broker | USD $3,783 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $38,367 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,783 | | Insurance broker organization code? | 3 |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 00490804 |
| Policy instance | 1 |
| Insurance contract or identification number | 00490804 | | Number of Individuals Covered | 614 | | Insurance policy start date | 2018-09-01 | | Insurance policy end date | 2019-08-31 | | Total amount of commissions paid to insurance broker | USD $54,624 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | 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 | AD&D, OPTIONAL LIFE | | 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 $496,236 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $54,624 | | Insurance broker organization code? | 3 |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 98857081001 |
| Policy instance | 2 |
| Insurance contract or identification number | 98857081001 | | Number of Individuals Covered | 469 | | Insurance policy start date | 2017-09-01 | | Insurance policy end date | 2018-08-31 | | Total amount of commissions paid to insurance broker | USD $3,637 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $33,808 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93440 ) |
| Policy contract number | 405637 0010 |
| Policy instance | 3 |
| Insurance contract or identification number | 405637 0010 | | Number of Individuals Covered | 354 | | Insurance policy start date | 2017-09-01 | | Insurance policy end date | 2018-08-31 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | 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 $316,661 | | 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 | 00490804 |
| Policy instance | 1 |
| Insurance contract or identification number | 00490804 | | Number of Individuals Covered | 579 | | Insurance policy start date | 2017-09-01 | | Insurance policy end date | 2018-08-31 | | Total amount of commissions paid to insurance broker | USD $44,583 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | 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 | AD&D, OPTIONAL LIFE | | 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 $416,842 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93440 ) |
| Policy contract number | 4056370010 |
| Policy instance | 4 |
| Insurance contract or identification number | 4056370010 | | Number of Individuals Covered | 348 | | Insurance policy start date | 2015-09-01 | | Insurance policy end date | 2016-08-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Welfare Benefit Premiums Paid to Carrier | USD $531,476 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | R0598920 |
| Policy instance | 3 |
| Insurance contract or identification number | R0598920 | | Number of Individuals Covered | 272 | | Insurance policy start date | 2015-09-01 | | Insurance policy end date | 2016-08-31 | | Total amount of commissions paid to insurance broker | USD $39,733 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $73,439 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $39,733 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | THE BENEFIT COMPANY |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 98857081001 |
| Policy instance | 2 |
| Insurance contract or identification number | 98857081001 | | Number of Individuals Covered | 409 | | Insurance policy start date | 2015-09-01 | | Insurance policy end date | 2016-08-31 | | Total amount of commissions paid to insurance broker | USD $2,835 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $26,694 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,835 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | THE BENEFIT COMPANY |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 00490804 |
| Policy instance | 1 |
| Insurance contract or identification number | 00490804 | | Number of Individuals Covered | 538 | | Insurance policy start date | 2015-09-01 | | Insurance policy end date | 2016-08-31 | | Total amount of commissions paid to insurance broker | USD $41,205 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D, OPTIONAL LIFE | | Welfare Benefit Premiums Paid to Carrier | USD $389,247 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $41,205 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | THE BENEFIT COMPANY |
|
| COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 ) |
| Policy contract number | E4025920 |
| Policy instance | 4 |
| Insurance contract or identification number | E4025920 | | Number of Individuals Covered | 192 | | Insurance policy start date | 2014-09-01 | | Insurance policy end date | 2015-08-31 | | Total amount of commissions paid to insurance broker | USD $35,810 | | Total amount of fees paid to insurance company | USD $19,777 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $127,551 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $35,810 | | Amount paid for insurance broker fees | 19777 | | Additional information about fees paid to insurance broker | OTHER FEES | | Insurance broker organization code? | 3 | | Insurance broker name | SEE ATTACHMENT |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 9885708 |
| Policy instance | 3 |
| Insurance contract or identification number | 9885708 | | Number of Individuals Covered | 360 | | Insurance policy start date | 2014-09-01 | | Insurance policy end date | 2015-08-31 | | Total amount of commissions paid to insurance broker | USD $2,110 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $23,242 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,283 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | THE BENEFIT COMPANY |
|
| KAISER FOUNDATION HEALTH PLAN OF GEORGIA INC. (National Association of Insurance Commissioners NAIC id number: 96237 ) |
| Policy contract number | 10100 |
| Policy instance | 2 |
| Insurance contract or identification number | 10100 | | Number of Individuals Covered | 358 | | Insurance policy start date | 2014-09-01 | | Insurance policy end date | 2015-08-31 | | Total amount of commissions paid to insurance broker | USD $81,366 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,626,331 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $54,697 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | THE BENEFIT COMPANY |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 00490804 |
| Policy instance | 1 |
| Insurance contract or identification number | 00490804 | | Number of Individuals Covered | 497 | | Insurance policy start date | 2014-09-01 | | Insurance policy end date | 2015-08-31 | | Total amount of commissions paid to insurance broker | USD $35,025 | | Total amount of fees paid to insurance company | USD $10,289 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Dental Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D, OPTIONAL LIFE | | Welfare Benefit Premiums Paid to Carrier | USD $338,841 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $20,361 | | Amount paid for insurance broker fees | 10289 | | Additional information about fees paid to insurance broker | BONUS | | Insurance broker organization code? | 3 | | Insurance broker name | THE BENEFIT COMPANY |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 00490804 |
| Policy instance | 2 |
| Insurance contract or identification number | 00490804 | | Number of Individuals Covered | 422 | | Insurance policy start date | 2013-09-01 | | Insurance policy end date | 2014-08-31 | | Total amount of commissions paid to insurance broker | USD $32,248 | | Total amount of fees paid to insurance company | USD $4,408 | | Dental Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D, OPTIONAL LIFEX | | Welfare Benefit Premiums Paid to Carrier | USD $313,432 | | Commission paid to Insurance Broker | USD $32,248 | | Amount paid for insurance broker fees | 4408 | | Additional information about fees paid to insurance broker | BONUS | | Insurance broker organization code? | 3 | | Insurance broker name | NORTHWESTERN BENEFIT CORP OF GA |
|
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) |
| Policy contract number | 9885708 |
| Policy instance | 1 |
| Insurance contract or identification number | 9885708 | | Number of Individuals Covered | 302 | | Insurance policy start date | 2013-09-01 | | Insurance policy end date | 2014-08-31 | | Total amount of commissions paid to insurance broker | USD $2,384 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $23,843 | | Commission paid to Insurance Broker | USD $2,384 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Insurance broker name | NORTHWESTERN BENEFIT CORP OF GA |
|
| KAISER FOUNDATION HEALTH PLAN OF GEORGIA INC. (National Association of Insurance Commissioners NAIC id number: 96237 ) |
| Policy contract number | 10100 |
| Policy instance | 3 |
| Insurance contract or identification number | 10100 | | Number of Individuals Covered | 359 | | Insurance policy start date | 2013-09-01 | | Insurance policy end date | 2014-08-31 | | Total amount of commissions paid to insurance broker | USD $73,498 | | Total amount of fees paid to insurance company | USD $34,280 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,470,888 | | Commission paid to Insurance Broker | USD $73,498 | | Amount paid for insurance broker fees | 34280 | | Additional information about fees paid to insurance broker | BONUS | | Insurance broker organization code? | 3 | | Insurance broker name | NORTHWESTERN BENEFIT CORP OF GA |
|
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | US442016 |
| Policy instance | 2 |
| Insurance contract or identification number | US442016 | | Number of Individuals Covered | 475 | | Insurance policy start date | 2012-09-01 | | Insurance policy end date | 2013-08-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,359,735 |
|
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 834962 |
| Policy instance | 3 |
| Insurance contract or identification number | 834962 | | Number of Individuals Covered | 410 | | Insurance policy start date | 2012-09-01 | | Insurance policy end date | 2013-08-31 | | Total amount of commissions paid to insurance broker | USD $18,146 | | Total amount of fees paid to insurance company | USD $64 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $317,209 | | Commission paid to Insurance Broker | USD $18,146 | | Amount paid for insurance broker fees | 64 | | Additional information about fees paid to insurance broker | BONUS | | Insurance broker organization code? | 3 | | Insurance broker name | NORTHWESTERN BENEFITS CORP OF GA |
|
| COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 ) |
| Policy contract number | E4025920 |
| Policy instance | 1 |
| Insurance contract or identification number | E4025920 | | Number of Individuals Covered | 60 | | Insurance policy start date | 2012-09-01 | | Insurance policy end date | 2013-08-31 | | Total amount of commissions paid to insurance broker | USD $18,930 | | Total amount of fees paid to insurance company | USD $9,973 | | Other welfare benefits provided | VOLUNTARY LIFE | | Welfare Benefit Premiums Paid to Carrier | USD $32,415 | | Commission paid to Insurance Broker | USD $8,645 | | Amount paid for insurance broker fees | 1968 | | Additional information about fees paid to insurance broker | BONUS | | Insurance broker organization code? | 3 | | Insurance broker name | CAROLINA BENEFITS SOURCE INC. |
|
| GREATER GEORGIA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 97217 ) |
| Policy contract number | GA2056 |
| Policy instance | 1 |
| Insurance contract or identification number | GA2056 | | Number of Individuals Covered | 0 | | Insurance policy start date | 2011-09-01 | | Insurance policy end date | 2012-08-31 | | Total amount of commissions paid to insurance broker | USD $304 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $0 |
|
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | US442016 |
| Policy instance | 3 |
| Insurance contract or identification number | US442016 | | Number of Individuals Covered | 563 | | Insurance policy start date | 2011-09-01 | | Insurance policy end date | 2012-08-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,330,943 |
|
| BLUE CROSS AND BLUE SHIELD OF GEORGIA, INC/ (G0385) (National Association of Insurance Commissioners NAIC id number: 54801 ) |
| Policy contract number | 1029920000 |
| Policy instance | 4 |
| Insurance contract or identification number | 1029920000 | | Number of Individuals Covered | 0 | | Insurance policy start date | 2011-09-01 | | Insurance policy end date | 2012-08-31 | | Total amount of commissions paid to insurance broker | USD $5,103 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $0 |
|
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 834962 |
| Policy instance | 2 |
| Insurance contract or identification number | 834962 | | Number of Individuals Covered | 476 | | Insurance policy start date | 2011-09-01 | | Insurance policy end date | 2012-08-31 | | Total amount of commissions paid to insurance broker | USD $32,919 | | Total amount of fees paid to insurance company | USD $20,823 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $213,132 |
|
| GREATER GEORGIA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 97217 ) |
| Policy contract number | GA2056 |
| Policy instance | 2 |
| Insurance contract or identification number | GA2056 | | Number of Individuals Covered | 341 | | Insurance policy start date | 2010-09-01 | | Insurance policy end date | 2011-08-31 | | Total amount of commissions paid to insurance broker | USD $5,631 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $55,084 |
|
| BLUE CROSS AND BLUE SHIELD OF GEORGIA, INC/ (G0385) (National Association of Insurance Commissioners NAIC id number: 54801 ) |
| Policy contract number | 1029920000 |
| Policy instance | 1 |
| Insurance contract or identification number | 1029920000 | | Number of Individuals Covered | 254 | | Insurance policy start date | 2010-09-01 | | Insurance policy end date | 2011-08-31 | | Total amount of commissions paid to insurance broker | USD $59,839 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,591,566 |
|
| GREATER GEORGIA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 97217 ) |
| Policy contract number | GA2056 |
| Policy instance | 1 |
| Insurance contract or identification number | GA2056 | | Number of Individuals Covered | 163 | | Insurance policy start date | 2008-09-01 | | Insurance policy end date | 2009-08-31 | | Total amount of commissions paid to insurance broker | USD $4,826 | | 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 | AD&D; VOL LIFE, VOL AD&D, VOL DEP LIFE | | 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 $47,223 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,826 | | Insurance broker organization code? | 3 | | Insurance broker name | NORTHWESTERN BENEFIT CORPORATION |
|
| BLUE CROSS AND BLUE SHIELD OF GEORGIA, INC/ (G0385) (National Association of Insurance Commissioners NAIC id number: 54801 ) |
| Policy contract number | G0385 |
| Policy instance | 2 |
| Insurance contract or identification number | G0385 | | Number of Individuals Covered | 286 | | Insurance policy start date | 2008-01-01 | | Insurance policy end date | 2008-08-31 | | Total amount of commissions paid to insurance broker | USD $52,936 | | 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 $0 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $52,936 | | Insurance broker organization code? | 3 | | Insurance broker name | NORTHWESTERN BENEFIT CORPORATION |
|
| BLUE CROSS AND BLUE SHIELD OF GEORGIA, INC/ (G0385) (National Association of Insurance Commissioners NAIC id number: 54801 ) |
| Policy contract number | 10299200000 |
| Policy instance | 1 |
| Insurance contract or identification number | 10299200000 | | Number of Individuals Covered | 147 | | Insurance policy start date | 2007-06-01 | | Insurance policy end date | 2008-05-31 | | Total amount of commissions paid to insurance broker | USD $65,557 | | 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 $0 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $65,557 | | Insurance broker organization code? | 3 | | Insurance broker name | NORTHWESTERN BENEFIT CORPORATION |
|
| BLUE CROSS AND BLUE SHIELD OF GEORGIA, INC/ (G0385) (National Association of Insurance Commissioners NAIC id number: 54801 ) |
| Policy contract number | 1029920000 |
| Policy instance | 1 |
| Insurance contract or identification number | 1029920000 | | Number of Individuals Covered | 149 | | Insurance policy start date | 2005-12-01 | | Insurance policy end date | 2006-11-30 | | Total amount of commissions paid to insurance broker | USD $33,350 | | 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 $0 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $27,541 | | Insurance broker organization code? | 3 | | Insurance broker name | NORTHWESTERN BENEFIT CORP OF GA |
|
