CONTERRA ULTRA BROADBAND, LLC has sponsored the creation of one or more 401k plans.
| Measure | Date | Value |
|---|
| 2022: CONTERRA ULTRA BROADBAND, LLC 2022 401k membership |
|---|
| Total participants, beginning-of-year | 2022-12-01 | 272 |
| Total number of active participants reported on line 7a of the Form 5500 | 2022-12-01 | 110 |
| Number of retired or separated participants receiving benefits | 2022-12-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2022-12-01 | 0 |
| Total of all active and inactive participants | 2022-12-01 | 110 |
| Number of employers contributing to the scheme | 2022-12-01 | 0 |
| 2021: CONTERRA ULTRA BROADBAND, LLC 2021 401k membership |
|---|
| Total participants, beginning-of-year | 2021-12-01 | 346 |
| Total number of active participants reported on line 7a of the Form 5500 | 2021-12-01 | 272 |
| Number of retired or separated participants receiving benefits | 2021-12-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2021-12-01 | 0 |
| Total of all active and inactive participants | 2021-12-01 | 272 |
| Number of employers contributing to the scheme | 2021-12-01 | 0 |
| 2020: CONTERRA ULTRA BROADBAND, LLC 2020 401k membership |
|---|
| Total participants, beginning-of-year | 2020-12-01 | 284 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-12-01 | 346 |
| Number of retired or separated participants receiving benefits | 2020-12-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2020-12-01 | 0 |
| Total of all active and inactive participants | 2020-12-01 | 346 |
| Number of employers contributing to the scheme | 2020-12-01 | 0 |
| 2019: CONTERRA ULTRA BROADBAND, LLC 2019 401k membership |
|---|
| Total participants, beginning-of-year | 2019-12-01 | 267 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-12-01 | 284 |
| Number of retired or separated participants receiving benefits | 2019-12-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2019-12-01 | 0 |
| Total of all active and inactive participants | 2019-12-01 | 284 |
| Number of employers contributing to the scheme | 2019-12-01 | 0 |
| 2018: CONTERRA ULTRA BROADBAND, LLC 2018 401k membership |
|---|
| Total participants, beginning-of-year | 2018-12-01 | 191 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-12-01 | 267 |
| Number of retired or separated participants receiving benefits | 2018-12-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2018-12-01 | 0 |
| Total of all active and inactive participants | 2018-12-01 | 267 |
| Number of employers contributing to the scheme | 2018-12-01 | 0 |
| 2017: CONTERRA ULTRA BROADBAND, LLC 2017 401k membership |
|---|
| Total participants, beginning-of-year | 2017-12-01 | 144 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-12-01 | 162 |
| Number of retired or separated participants receiving benefits | 2017-12-01 | 1 |
| Number of other retired or separated participants entitled to future benefits | 2017-12-01 | 0 |
| Total of all active and inactive participants | 2017-12-01 | 163 |
| Number of employers contributing to the scheme | 2017-12-01 | 0 |
| 2016: CONTERRA ULTRA BROADBAND, LLC 2016 401k membership |
|---|
| Total participants, beginning-of-year | 2016-12-01 | 169 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-12-01 | 144 |
| Number of retired or separated participants receiving benefits | 2016-12-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2016-12-01 | 0 |
| Total of all active and inactive participants | 2016-12-01 | 144 |
| 2015: CONTERRA ULTRA BROADBAND, LLC 2015 401k membership |
|---|
| Total participants, beginning-of-year | 2015-12-01 | 155 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-12-01 | 169 |
| Number of retired or separated participants receiving benefits | 2015-12-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2015-12-01 | 0 |
| Total of all active and inactive participants | 2015-12-01 | 169 |
| 2014: CONTERRA ULTRA BROADBAND, LLC 2014 401k membership |
|---|
| Total participants, beginning-of-year | 2014-12-01 | 125 |
| Total number of active participants reported on line 7a of the Form 5500 | 2014-12-01 | 155 |
| Number of retired or separated participants receiving benefits | 2014-12-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2014-12-01 | 0 |
| Total of all active and inactive participants | 2014-12-01 | 155 |
| 2022: CONTERRA ULTRA BROADBAND, LLC 2022 form 5500 responses |
|---|
| 2022-12-01 | Type of plan entity | Single employer plan |
| 2022-12-01 | Plan funding arrangement – Insurance | Yes |
| 2022-12-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2022-12-01 | Plan benefit arrangement – Insurance | Yes |
| 2022-12-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2021: CONTERRA ULTRA BROADBAND, LLC 2021 form 5500 responses |
|---|
| 2021-12-01 | Type of plan entity | Single employer plan |
| 2021-12-01 | Plan funding arrangement – Insurance | Yes |
| 2021-12-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2021-12-01 | Plan benefit arrangement – Insurance | Yes |
| 2021-12-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2020: CONTERRA ULTRA BROADBAND, LLC 2020 form 5500 responses |
|---|
| 2020-12-01 | Type of plan entity | Single employer plan |
| 2020-12-01 | Plan funding arrangement – Insurance | Yes |
| 2020-12-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2020-12-01 | Plan benefit arrangement – Insurance | Yes |
| 2020-12-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2019: CONTERRA ULTRA BROADBAND, LLC 2019 form 5500 responses |
|---|
| 2019-12-01 | Type of plan entity | Single employer plan |
| 2019-12-01 | Plan funding arrangement – Insurance | Yes |
| 2019-12-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2019-12-01 | Plan benefit arrangement – Insurance | Yes |
| 2019-12-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2018: CONTERRA ULTRA BROADBAND, LLC 2018 form 5500 responses |
|---|
| 2018-12-01 | Type of plan entity | Single employer plan |
| 2018-12-01 | Submission has been amended | Yes |
| 2018-12-01 | Plan funding arrangement – Insurance | Yes |
| 2018-12-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2018-12-01 | Plan benefit arrangement – Insurance | Yes |
| 2018-12-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2017: CONTERRA ULTRA BROADBAND, LLC 2017 form 5500 responses |
|---|
| 2017-12-01 | Type of plan entity | Single employer plan |
| 2017-12-01 | Plan funding arrangement – Insurance | Yes |
| 2017-12-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2017-12-01 | Plan benefit arrangement – Insurance | Yes |
| 2017-12-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2016: CONTERRA ULTRA BROADBAND, LLC 2016 form 5500 responses |
|---|
| 2016-12-01 | Type of plan entity | Single employer plan |
| 2016-12-01 | Plan funding arrangement – Insurance | Yes |
| 2016-12-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2016-12-01 | Plan benefit arrangement – Insurance | Yes |
| 2016-12-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2015: CONTERRA ULTRA BROADBAND, LLC 2015 form 5500 responses |
|---|
| 2015-12-01 | Type of plan entity | Single employer plan |
| 2015-12-01 | Submission has been amended | No |
| 2015-12-01 | This submission is the final filing | No |
| 2015-12-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2015-12-01 | Plan is a collectively bargained plan | No |
| 2015-12-01 | Plan funding arrangement – Insurance | Yes |
| 2015-12-01 | Plan benefit arrangement – Insurance | Yes |
| 2014: CONTERRA ULTRA BROADBAND, LLC 2014 form 5500 responses |
|---|
| 2014-12-01 | Type of plan entity | Single employer plan |
| 2014-12-01 | First time form 5500 has been submitted | Yes |
| 2014-12-01 | Submission has been amended | No |
| 2014-12-01 | This submission is the final filing | No |
| 2014-12-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2014-12-01 | Plan is a collectively bargained plan | No |
| 2014-12-01 | Plan funding arrangement – Insurance | Yes |
| 2014-12-01 | Plan benefit arrangement – Insurance | Yes |
| SYMETRA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68608 ) |
| Policy contract number | 01-020373-00 |
| Policy instance | 2 |
| Insurance contract or identification number | 01-020373-00 | | Number of Individuals Covered | 110 | | Insurance policy start date | 2022-12-01 | | Insurance policy end date | 2023-11-30 | | Total amount of commissions paid to insurance broker | USD $55,662 | | Total amount of fees paid to insurance company | USD $12,710 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $278,309 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $41,746 | | Amount paid for insurance broker fees | 12710 | | Additional information about fees paid to insurance broker | GROUP VOLUME BONUS | | Insurance broker organization code? | 3 |
|
| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
| Policy contract number | 886578G |
| Policy instance | 1 |
| Insurance contract or identification number | 886578G | | Number of Individuals Covered | 110 | | Insurance policy start date | 2022-12-01 | | Insurance policy end date | 2023-11-30 | | Total amount of commissions paid to insurance broker | USD $15,791 | | Total amount of fees paid to insurance company | USD $3,984 | | Other welfare benefits provided | ACCIDENT, CRITICAL ILLNESS | | Welfare Benefit Premiums Paid to Carrier | USD $60,823 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $15,791 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Additional information about fees paid to insurance broker | FEES |
|
| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
| Policy contract number | 886578G |
| Policy instance | 1 |
| Insurance contract or identification number | 886578G | | Number of Individuals Covered | 107 | | Insurance policy start date | 2021-12-01 | | Insurance policy end date | 2022-11-30 | | Total amount of commissions paid to insurance broker | USD $15,112 | | Total amount of fees paid to insurance company | USD $3,480 | | Other welfare benefits provided | ACCIDENT, CRITICAL ILLNESS | | Welfare Benefit Premiums Paid to Carrier | USD $26,316 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $15,112 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Additional information about fees paid to insurance broker | FEES |
|
| BLUECROSS BLUESHIELD OF NORTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 54631 ) |
| Policy contract number | 14159296-1001 |
| Policy instance | 2 |
| Insurance contract or identification number | 14159296-1001 | | Number of Individuals Covered | 604 | | Insurance policy start date | 2021-12-01 | | Insurance policy end date | 2022-11-30 | | Total amount of commissions paid to insurance broker | USD $67,580 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $2,999,496 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $67,580 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 ) |
| Policy contract number | 010-052201 |
| Policy instance | 3 |
| Insurance contract or identification number | 010-052201 | | Number of Individuals Covered | 598 | | Insurance policy start date | 2021-12-01 | | Insurance policy end date | 2022-11-30 | | Total amount of commissions paid to insurance broker | USD $24,712 | | Total amount of fees paid to insurance company | USD $4,688 | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $247,119 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $24,712 | | Amount paid for insurance broker fees | 4688 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker organization code? | 3 |
|
| SYMETRA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68608 ) |
| Policy contract number | 01-020373-00 |
| Policy instance | 4 |
| Insurance contract or identification number | 01-020373-00 | | Number of Individuals Covered | 272 | | Insurance policy start date | 2021-12-01 | | Insurance policy end date | 2022-11-30 | | Total amount of commissions paid to insurance broker | USD $51,701 | | Total amount of fees paid to insurance company | USD $5,807 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $258,505 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $38,776 | | Amount paid for insurance broker fees | 5807 | | Additional information about fees paid to insurance broker | GROUP VOLUME BONUS | | Insurance broker organization code? | 3 |
|
| AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 ) |
| Policy contract number | 010-052201 |
| Policy instance | 3 |
| Insurance contract or identification number | 010-052201 | | Number of Individuals Covered | 499 | | Insurance policy start date | 2020-12-01 | | Insurance policy end date | 2021-11-30 | | Total amount of commissions paid to insurance broker | USD $21,722 | | Total amount of fees paid to insurance company | USD $3,168 | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $217,217 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $21,722 | | Amount paid for insurance broker fees | 3168 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker organization code? | 3 |
|
| BLUECROSS BLUESHIELD OF NORTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 54631 ) |
| Policy contract number | 14159296-1001 |
| Policy instance | 2 |
| Insurance contract or identification number | 14159296-1001 | | Number of Individuals Covered | 516 | | Insurance policy start date | 2020-12-01 | | Insurance policy end date | 2021-11-30 | | Total amount of commissions paid to insurance broker | USD $53,700 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $2,585,537 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $53,700 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
| Policy contract number | 886578G |
| Policy instance | 1 |
| Insurance contract or identification number | 886578G | | Number of Individuals Covered | 346 | | Insurance policy start date | 2020-12-01 | | Insurance policy end date | 2021-11-30 | | Total amount of commissions paid to insurance broker | USD $33,535 | | Total amount of fees paid to insurance company | USD $18,430 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT, ACCIDENT, CRITICAL ILLNESS | | Welfare Benefit Premiums Paid to Carrier | USD $226,345 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $33,535 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Additional information about fees paid to insurance broker | FEES |
|
| AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 ) |
| Policy contract number | 010-052201 |
| Policy instance | 3 |
| Insurance contract or identification number | 010-052201 | | Number of Individuals Covered | 481 | | Insurance policy start date | 2019-12-01 | | Insurance policy end date | 2020-11-30 | | Total amount of commissions paid to insurance broker | USD $20,524 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $189,465 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $20,524 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| BLUECROSS BLUESHIELD OF NORTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 54631 ) |
| Policy contract number | 141592961001 |
| Policy instance | 2 |
| Insurance contract or identification number | 141592961001 | | Number of Individuals Covered | 307 | | Insurance policy start date | 2019-12-01 | | Insurance policy end date | 2020-11-30 | | Total amount of commissions paid to insurance broker | USD $45,700 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $2,350,714 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $45,700 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
| Policy contract number | 886578G |
| Policy instance | 1 |
| Insurance contract or identification number | 886578G | | Number of Individuals Covered | 284 | | Insurance policy start date | 2019-12-01 | | Insurance policy end date | 2020-11-30 | | Total amount of commissions paid to insurance broker | USD $42,940 | | Total amount of fees paid to insurance company | USD $14,799 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT, ACCIDENT, CRITICAL ILLNESS | | Welfare Benefit Premiums Paid to Carrier | USD $223,744 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $42,940 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Additional information about fees paid to insurance broker | FEES |
|
| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
| Policy contract number | 5940332 |
| Policy instance | 3 |
| Insurance contract or identification number | 5940332 | | Number of Individuals Covered | 553 | | Insurance policy start date | 2018-12-01 | | Insurance policy end date | 2019-11-30 | | Total amount of commissions paid to insurance broker | USD $26,847 | | Total amount of fees paid to insurance company | USD $2,297 | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $173,103 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $22,413 | | Amount paid for insurance broker fees | 60 | | Additional information about fees paid to insurance broker | NON-MONETARY COMPENSATION | | Insurance broker organization code? | 3 |
|
| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
| Policy contract number | 886578G |
| Policy instance | 1 |
| Insurance contract or identification number | 886578G | | Number of Individuals Covered | 260 | | Insurance policy start date | 2018-12-01 | | Insurance policy end date | 2019-11-30 | | Total amount of commissions paid to insurance broker | USD $34,360 | | Total amount of fees paid to insurance company | USD $12,825 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT, ACCIDENT, CRITICAL ILLNESS | | Welfare Benefit Premiums Paid to Carrier | USD $183,412 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $34,360 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 | | Additional information about fees paid to insurance broker | FEES |
|
| BLUECROSS BLUESHIELD OF NORTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 54631 ) |
| Policy contract number | 67471 |
| Policy instance | 2 |
| Insurance contract or identification number | 67471 | | Number of Individuals Covered | 453 | | Insurance policy start date | 2018-12-01 | | Insurance policy end date | 2019-11-30 | | Total amount of commissions paid to insurance broker | USD $52,649 | | Total amount of fees paid to insurance company | USD $767 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $2,157,730 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $52,649 | | Amount paid for insurance broker fees | 767 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker organization code? | 3 |
|
| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
| Policy contract number | TM05940332 |
| Policy instance | 2 |
| Insurance contract or identification number | TM05940332 | | Number of Individuals Covered | 470 | | Insurance policy start date | 2017-12-01 | | Insurance policy end date | 2018-11-30 | | Total amount of commissions paid to insurance broker | USD $33,016 | | Total amount of fees paid to insurance company | USD $3,056 | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $223,868 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| BLUECROSS BLUESHIELD OF NORTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 54631 ) |
| Policy contract number | 67471 |
| Policy instance | 1 |
| Insurance contract or identification number | 67471 | | Number of Individuals Covered | 341 | | Insurance policy start date | 2017-12-01 | | Insurance policy end date | 2018-11-30 | | Total amount of commissions paid to insurance broker | USD $36,047 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,478,324 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 ) |
| Policy contract number | 010-041333 |
| Policy instance | 1 |
| Insurance contract or identification number | 010-041333 | | Number of Individuals Covered | 261 | | Insurance policy start date | 2015-12-01 | | Insurance policy end date | 2016-11-30 | | Total amount of commissions paid to insurance broker | USD $12,191 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | 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 $98,048 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $9,805 | | Insurance broker organization code? | 3 | | Insurance broker name | WELLS FARGO INSURANCE |
|
| USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 ) |
| Policy contract number | 50015545 |
| Policy instance | 2 |
| Insurance contract or identification number | 50015545 | | Number of Individuals Covered | 155 | | Insurance policy start date | 2015-12-01 | | Insurance policy end date | 2016-11-30 | | Total amount of commissions paid to insurance broker | USD $9,647 | | 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 | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $24,094 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,441 | | Insurance broker organization code? | 3 | | Insurance broker name | MOSAIC GROUP |
|
| BLUECROSS BLUESHIELD OF NORTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 54631 ) |
| Policy contract number | 67471 |
| Policy instance | 3 |
| Insurance contract or identification number | 67471 | | Number of Individuals Covered | 279 | | Insurance policy start date | 2015-12-01 | | Insurance policy end date | 2016-11-30 | | Total amount of commissions paid to insurance broker | USD $26,970 | | Total amount of fees paid to insurance company | USD $1,000 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $1,032,984 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $26,970 | | Amount paid for insurance broker fees | 1000 | | Additional information about fees paid to insurance broker | FEES | | Insurance broker organization code? | 3 | | Insurance broker name | SCOTT C. ANDERSON |
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| AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 ) |
| Policy contract number | 010-041333 |
| Policy instance | 1 |
| Insurance contract or identification number | 010-041333 | | Number of Individuals Covered | 231 | | Insurance policy start date | 2014-12-01 | | Insurance policy end date | 2015-11-30 | | Total amount of commissions paid to insurance broker | USD $5,222 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | No | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Are there contracts with unallocated funds for contracts of type immediate participation guarantee? | No | | Are there contracts with unallocated funds for contracts of type guaranteed investment? | No | | Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment? | No | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $57,510 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,991 | | Insurance broker organization code? | 3 | | Insurance broker name | WELLS FARGO INSURANCE SERVICES |
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| BLUECROSS BLUESHIELD OF NORTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 54631 ) |
| Policy contract number | 67471 |
| Policy instance | 3 |
| Insurance contract or identification number | 67471 | | Number of Individuals Covered | 227 | | Insurance policy start date | 2014-12-01 | | Insurance policy end date | 2015-11-30 | | Total amount of commissions paid to insurance broker | USD $25,285 | | 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 $888,958 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $25,285 | | Insurance broker organization code? | 3 | | Insurance broker name | WELLS FARGO INSURANCE SERVICES |
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| USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 ) |
| Policy contract number | 50015545 |
| Policy instance | 2 |
| Insurance contract or identification number | 50015545 | | Number of Individuals Covered | 142 | | Insurance policy start date | 2014-12-01 | | Insurance policy end date | 2015-11-30 | | Total amount of commissions paid to insurance broker | USD $12,956 | | 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 | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $71,973 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,596 | | Insurance broker organization code? | 3 | | Insurance broker name | WELLS FARGO INSURANCE SERVICES |
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