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AMERICAN INSULATED GLASS CO. HEALTH AND WELFARE PLAN 401k Plan overview

Plan NameAMERICAN INSULATED GLASS CO. HEALTH AND WELFARE PLAN
Plan identification number 501

AMERICAN INSULATED GLASS CO. HEALTH AND WELFARE 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)
  • Other welfare benefit cover

401k Sponsoring company profile

AMERICAN INSULATED GLASS LLC has sponsored the creation of one or more 401k plans.

Company Name:AMERICAN INSULATED GLASS LLC
Employer identification number (EIN):581920582
NAIC Classification:327210

Form 5500 Filing Information

Submission information for form 5500 for 401k plan AMERICAN INSULATED GLASS CO. HEALTH AND WELFARE PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5012023-01-01
5012022-01-01
5012022-01-01
5012021-01-01
5012020-01-01JAY WEEKS2021-04-30
5012019-01-01JAY WEEKS2020-05-18
5012018-10-01
5012017-10-01JENNIFER WADE2019-04-04
5012016-10-01JENNIFER WADE
5012015-10-01KELLEY FREEMAN

Plan Statistics for AMERICAN INSULATED GLASS CO. HEALTH AND WELFARE PLAN

401k plan membership statisitcs for AMERICAN INSULATED GLASS CO. HEALTH AND WELFARE PLAN

Measure Date Value
2023: AMERICAN INSULATED GLASS CO. HEALTH AND WELFARE PLAN 2023 401k membership
Total participants, beginning-of-year2023-01-01474
Total number of active participants reported on line 7a of the Form 55002023-01-01432
Number of retired or separated participants receiving benefits2023-01-010
Number of other retired or separated participants entitled to future benefits2023-01-010
Total of all active and inactive participants2023-01-01432
2022: AMERICAN INSULATED GLASS CO. HEALTH AND WELFARE PLAN 2022 401k membership
Total participants, beginning-of-year2022-01-01409
Total number of active participants reported on line 7a of the Form 55002022-01-01186
Number of retired or separated participants receiving benefits2022-01-010
Number of other retired or separated participants entitled to future benefits2022-01-010
Total of all active and inactive participants2022-01-01186
2021: AMERICAN INSULATED GLASS CO. HEALTH AND WELFARE PLAN 2021 401k membership
Total participants, beginning-of-year2021-01-01354
Total number of active participants reported on line 7a of the Form 55002021-01-01409
Number of retired or separated participants receiving benefits2021-01-010
Number of other retired or separated participants entitled to future benefits2021-01-010
Total of all active and inactive participants2021-01-01409
2020: AMERICAN INSULATED GLASS CO. HEALTH AND WELFARE PLAN 2020 401k membership
Total participants, beginning-of-year2020-01-01254
Total number of active participants reported on line 7a of the Form 55002020-01-01354
Number of retired or separated participants receiving benefits2020-01-010
Number of other retired or separated participants entitled to future benefits2020-01-010
Total of all active and inactive participants2020-01-01354
2019: AMERICAN INSULATED GLASS CO. HEALTH AND WELFARE PLAN 2019 401k membership
Total participants, beginning-of-year2019-01-01145
Total number of active participants reported on line 7a of the Form 55002019-01-01254
Number of retired or separated participants receiving benefits2019-01-010
Number of other retired or separated participants entitled to future benefits2019-01-010
Total of all active and inactive participants2019-01-01254
2018: AMERICAN INSULATED GLASS CO. HEALTH AND WELFARE PLAN 2018 401k membership
Total participants, beginning-of-year2018-10-01151
Total number of active participants reported on line 7a of the Form 55002018-10-01145
Number of retired or separated participants receiving benefits2018-10-010
Number of other retired or separated participants entitled to future benefits2018-10-010
Total of all active and inactive participants2018-10-01145
Number of employers contributing to the scheme2018-10-010
2017: AMERICAN INSULATED GLASS CO. HEALTH AND WELFARE PLAN 2017 401k membership
Total participants, beginning-of-year2017-10-01139
Total number of active participants reported on line 7a of the Form 55002017-10-01151
Number of retired or separated participants receiving benefits2017-10-010
Number of other retired or separated participants entitled to future benefits2017-10-010
Total of all active and inactive participants2017-10-01151
Number of employers contributing to the scheme2017-10-010
2016: AMERICAN INSULATED GLASS CO. HEALTH AND WELFARE PLAN 2016 401k membership
Total participants, beginning-of-year2016-10-01123
Total number of active participants reported on line 7a of the Form 55002016-10-01139
Number of retired or separated participants receiving benefits2016-10-010
Number of other retired or separated participants entitled to future benefits2016-10-010
Total of all active and inactive participants2016-10-01139
2015: AMERICAN INSULATED GLASS CO. HEALTH AND WELFARE PLAN 2015 401k membership
Total participants, beginning-of-year2015-10-01107
Total number of active participants reported on line 7a of the Form 55002015-10-01117
Number of retired or separated participants receiving benefits2015-10-010
Number of other retired or separated participants entitled to future benefits2015-10-010
Total of all active and inactive participants2015-10-01117

Form 5500 Responses for AMERICAN INSULATED GLASS CO. HEALTH AND WELFARE PLAN

2023: AMERICAN INSULATED GLASS CO. HEALTH AND WELFARE PLAN 2023 form 5500 responses
2023-01-01Type of plan entitySingle employer plan
2023-01-01Submission has been amendedNo
2023-01-01This submission is the final filingNo
2023-01-01This return/report is a short plan year return/report (less than 12 months)No
2023-01-01Plan is a collectively bargained planNo
2023-01-01Plan funding arrangement – InsuranceYes
2023-01-01Plan funding arrangement – General assets of the sponsorYes
2023-01-01Plan benefit arrangement – InsuranceYes
2023-01-01Plan benefit arrangement – General assets of the sponsorYes
2022: AMERICAN INSULATED GLASS CO. HEALTH AND WELFARE PLAN 2022 form 5500 responses
2022-01-01Type of plan entitySingle employer plan
2022-01-01Submission has been amendedNo
2022-01-01This submission is the final filingNo
2022-01-01This return/report is a short plan year return/report (less than 12 months)No
2022-01-01Plan is a collectively bargained planNo
2022-01-01Plan funding arrangement – InsuranceYes
2022-01-01Plan funding arrangement – General assets of the sponsorYes
2022-01-01Plan benefit arrangement – InsuranceYes
2022-01-01Plan benefit arrangement – General assets of the sponsorYes
2021: AMERICAN INSULATED GLASS CO. HEALTH AND WELFARE PLAN 2021 form 5500 responses
2021-01-01Type of plan entitySingle employer plan
2021-01-01Submission has been amendedNo
2021-01-01This submission is the final filingNo
2021-01-01This return/report is a short plan year return/report (less than 12 months)No
2021-01-01Plan is a collectively bargained planNo
2021-01-01Plan funding arrangement – InsuranceYes
2021-01-01Plan funding arrangement – General assets of the sponsorYes
2021-01-01Plan benefit arrangement – InsuranceYes
2021-01-01Plan benefit arrangement – General assets of the sponsorYes
2020: AMERICAN INSULATED GLASS CO. HEALTH AND WELFARE PLAN 2020 form 5500 responses
2020-01-01Type of plan entitySingle employer plan
2020-01-01Submission has been amendedNo
2020-01-01This submission is the final filingNo
2020-01-01This return/report is a short plan year return/report (less than 12 months)No
2020-01-01Plan is a collectively bargained planNo
2020-01-01Plan funding arrangement – InsuranceYes
2020-01-01Plan benefit arrangement – InsuranceYes
2019: AMERICAN INSULATED GLASS CO. HEALTH AND WELFARE PLAN 2019 form 5500 responses
2019-01-01Type of plan entitySingle employer plan
2019-01-01Submission has been amendedNo
2019-01-01This submission is the final filingNo
2019-01-01This return/report is a short plan year return/report (less than 12 months)No
2019-01-01Plan is a collectively bargained planNo
2019-01-01Plan funding arrangement – InsuranceYes
2019-01-01Plan benefit arrangement – InsuranceYes
2018: AMERICAN INSULATED GLASS CO. HEALTH AND WELFARE PLAN 2018 form 5500 responses
2018-10-01Type of plan entitySingle employer plan
2018-10-01This return/report is a short plan year return/report (less than 12 months)Yes
2018-10-01Plan funding arrangement – InsuranceYes
2018-10-01Plan benefit arrangement – InsuranceYes
2017: AMERICAN INSULATED GLASS CO. HEALTH AND WELFARE PLAN 2017 form 5500 responses
2017-10-01Type of plan entitySingle employer plan
2017-10-01Plan funding arrangement – InsuranceYes
2017-10-01Plan benefit arrangement – InsuranceYes
2016: AMERICAN INSULATED GLASS CO. HEALTH AND WELFARE PLAN 2016 form 5500 responses
2016-10-01Type of plan entitySingle employer plan
2016-10-01Submission has been amendedNo
2016-10-01This submission is the final filingNo
2016-10-01This return/report is a short plan year return/report (less than 12 months)No
2016-10-01Plan is a collectively bargained planNo
2016-10-01Plan funding arrangement – InsuranceYes
2016-10-01Plan benefit arrangement – InsuranceYes
2015: AMERICAN INSULATED GLASS CO. HEALTH AND WELFARE PLAN 2015 form 5500 responses
2015-10-01Type of plan entitySingle employer plan
2015-10-01First time form 5500 has been submittedYes
2015-10-01Submission has been amendedNo
2015-10-01This submission is the final filingNo
2015-10-01This return/report is a short plan year return/report (less than 12 months)No
2015-10-01Plan is a collectively bargained planNo
2015-10-01Plan funding arrangement – InsuranceYes
2015-10-01Plan benefit arrangement – InsuranceYes

Insurance Providers Used on plan

GREATER GEORGIA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 97217 )
Policy contract numberCM10000536
Policy instance 2
Insurance contract or identification numberCM10000536
Number of Individuals Covered432
Insurance policy start date2023-01-01
Insurance policy end date2023-12-31
Total amount of commissions paid to insurance brokerUSD $27,661
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH & DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $180,778
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 numberGB0591
Policy instance 1
Insurance contract or identification numberGB0591
Number of Individuals Covered309
Insurance policy start date2023-01-01
Insurance policy end date2023-12-31
Total amount of commissions paid to insurance brokerUSD $90,662
Total amount of fees paid to insurance companyUSD $1,096
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 planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $2,478,210
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 numberCM10000536
Policy instance 2
Insurance contract or identification numberCM10000536
Number of Individuals Covered474
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $23,178
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH & DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $167,841
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $23,178
Insurance broker organization code?3
BLUE CROSS BLUE SHIELD OF GEORGIA INC. (G0386) (National Association of Insurance Commissioners NAIC id number: 96962 )
Policy contract numberGB0591
Policy instance 1
Insurance contract or identification numberGB0591
Number of Individuals Covered340
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $77,679
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $2,227,108
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $77,679
Insurance broker organization code?3
BLUE CROSS BLUE SHIELD OF GEORGIA INC. (G0386) (National Association of Insurance Commissioners NAIC id number: 96962 )
Policy contract numberGB0591*
Policy instance 1
Insurance contract or identification numberGB0591*
Number of Individuals Covered203
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $90,296
Total amount of fees paid to insurance companyUSD $5,196
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 planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $1,762,343
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $42,492
Amount paid for insurance broker fees622
Additional information about fees paid to insurance brokerFEES PAID
Insurance broker organization code?3
GREATER GEORGIA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 97217 )
Policy contract numberCM10000536
Policy instance 2
Insurance contract or identification numberCM10000536
Number of Individuals Covered409
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $20,713
Total amount of fees paid to insurance companyUSD $5,211
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 planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH & DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $138,089
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $10,685
Insurance broker organization code?3
Amount paid for insurance broker fees5211
Additional information about fees paid to insurance brokerFEES PAID
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number5486721
Policy instance 6
Insurance contract or identification number5486721
Number of Individuals Covered29
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $2,837
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedGAP
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,837
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerN/A
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGVTL0BMVK
Policy instance 5
Insurance contract or identification numberGVTL0BMVK
Number of Individuals Covered121
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $6,836
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedVOLUNTARY LIFE, VOLUNTARY AD&D
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $45,573
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6,836
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerN/A
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGUPR0BMVK
Policy instance 4
Insurance contract or identification numberGUPR0BMVK
Number of Individuals Covered96
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $7,239
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $48,258
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $7,239
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerN/A
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGUC0BMVK
Policy instance 3
Insurance contract or identification numberGUC0BMVK
Number of Individuals Covered119
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $4,296
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $28,641
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,296
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerN/A
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLUG0BMVK
Policy instance 2
Insurance contract or identification numberGLUG0BMVK
Number of Individuals Covered354
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $2,673
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&D
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $17,820
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,673
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerN/A
Insurance broker organization code?3
BLUE CROSS BLUE SHIELD OF GEORGIA INC. (G0386) (National Association of Insurance Commissioners NAIC id number: 96962 )
Policy contract numberGB0591
Policy instance 1
Insurance contract or identification numberGB0591
Number of Individuals Covered194
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $73,701
Total amount of fees paid to insurance companyUSD $4,878
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 planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $1,467,950
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $73,701
Amount paid for insurance broker fees4878
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number0106396
Policy instance 1
Insurance contract or identification number0106396
Number of Individuals Covered254
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $16,136
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT, EMPLOYEE ASSISTANCE PROGRAM
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $349,010
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $16,136
Amount paid for insurance broker fees0
Additional information about fees paid to insurance brokerN/A
Insurance broker organization code?3
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number5486721
Policy instance 2
Insurance contract or identification number5486721
Number of Individuals Covered27
Insurance policy start date2019-10-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $2,349
Total amount of fees paid to insurance companyUSD $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 planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedHOSPITAL
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $2,349
Insurance broker organization code?3
AETNA HEALTH, INC. (National Association of Insurance Commissioners NAIC id number: 95094 )
Policy contract number0106396HNO
Policy instance 3
Insurance contract or identification number0106396HNO
Number of Individuals Covered153
Insurance policy start date2019-10-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $25
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 planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $569,674
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $0
Amount paid for insurance broker fees25
Additional information about fees paid to insurance brokerDIRECT COMPENSATION
Insurance broker organization code?3
AETNA HEALTH, INC. (National Association of Insurance Commissioners NAIC id number: 95094 )
Policy contract number0106396HNO
Policy instance 3
Insurance contract or identification number0106396HNO
Number of Individuals Covered145
Insurance policy start date2018-10-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $6,295
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $143,956
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $0
Amount paid for insurance broker fees6295
Additional information about fees paid to insurance brokerDIRECT COMPENSATION
Insurance broker organization code?3
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number5486721
Policy instance 2
Insurance contract or identification number5486721
Number of Individuals Covered18
Insurance policy start date2018-10-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $271
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedHOSPITAL
Welfare Benefit Premiums Paid to CarrierUSD $1,804
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $271
Amount paid for insurance broker fees0
Insurance broker organization code?3
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number0106396
Policy instance 1
Insurance contract or identification number0106396
Number of Individuals Covered201
Insurance policy start date2018-10-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $4,148
Total amount of fees paid to insurance companyUSD $2,305
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT, EMPLOYEE ASSISTANCE PROGRAM
Welfare Benefit Premiums Paid to CarrierUSD $93,215
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,148
Amount paid for insurance broker fees2305
Additional information about fees paid to insurance brokerDIRECT COMPENSATION
Insurance broker organization code?3
AETNA HEALTH, INC. (National Association of Insurance Commissioners NAIC id number: 95094 )
Policy contract number0106396HNO
Policy instance 1
Insurance contract or identification number0106396HNO
Number of Individuals Covered152
Insurance policy start date2017-10-01
Insurance policy end date2018-09-30
Total amount of commissions paid to insurance brokerUSD $9,487
Total amount of fees paid to insurance companyUSD $16,638
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $403,414
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number0106396
Policy instance 2
Insurance contract or identification number0106396
Number of Individuals Covered202
Insurance policy start date2017-10-01
Insurance policy end date2018-09-30
Total amount of commissions paid to insurance brokerUSD $15,604
Total amount of fees paid to insurance companyUSD $8,808
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT, EMPLOYEE ASSISTANCE PROGRAM
Welfare Benefit Premiums Paid to CarrierUSD $238,281
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 number5486721
Policy instance 3
Insurance contract or identification number5486721
Number of Individuals Covered14
Insurance policy start date2017-10-01
Insurance policy end date2018-09-30
Total amount of commissions paid to insurance brokerUSD $960
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedHOSPITAL
Welfare Benefit Premiums Paid to CarrierUSD $6,399
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes

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