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DAVIS EXPRESS, INC. HEALTH AND WELFARE PLAN 401k Plan overview

Plan NameDAVIS EXPRESS, INC. HEALTH AND WELFARE PLAN
Plan identification number 501

DAVIS EXPRESS, INC. 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

DAVIS EXPRESS INC. has sponsored the creation of one or more 401k plans.

Company Name:DAVIS EXPRESS INC.
Employer identification number (EIN):592095705
NAIC Classification:484110
NAIC Description:General Freight Trucking, Local

Form 5500 Filing Information

Submission information for form 5500 for 401k plan DAVIS EXPRESS, INC. HEALTH AND WELFARE PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5012021-09-15
5012020-09-15
5012019-09-15
5012018-09-15
5012017-09-15
5012016-09-15PAM MARTIN
5012015-09-15GLENDA PARISH
5012014-09-15PAM MARTIN
5012013-09-15PAM MARTIN
5012012-09-15PAM MARTIN
5012011-09-15PAM MARTIN
5012010-09-15PAM MARTIN
5012009-09-15PAM MARTIN
5012008-09-15PAM MARTIN
5012007-09-15PAM MARTIN

Plan Statistics for DAVIS EXPRESS, INC. HEALTH AND WELFARE PLAN

401k plan membership statisitcs for DAVIS EXPRESS, INC. HEALTH AND WELFARE PLAN

Measure Date Value
2021: DAVIS EXPRESS, INC. HEALTH AND WELFARE PLAN 2021 401k membership
Total participants, beginning-of-year2021-09-15196
Total number of active participants reported on line 7a of the Form 55002021-09-15171
Number of retired or separated participants receiving benefits2021-09-151
Number of other retired or separated participants entitled to future benefits2021-09-150
Total of all active and inactive participants2021-09-15172
2020: DAVIS EXPRESS, INC. HEALTH AND WELFARE PLAN 2020 401k membership
Total participants, beginning-of-year2020-09-15214
Total number of active participants reported on line 7a of the Form 55002020-09-15196
Number of retired or separated participants receiving benefits2020-09-151
Number of other retired or separated participants entitled to future benefits2020-09-150
Total of all active and inactive participants2020-09-15197
2019: DAVIS EXPRESS, INC. HEALTH AND WELFARE PLAN 2019 401k membership
Total participants, beginning-of-year2019-09-15222
Total number of active participants reported on line 7a of the Form 55002019-09-15214
Number of retired or separated participants receiving benefits2019-09-152
Number of other retired or separated participants entitled to future benefits2019-09-150
Total of all active and inactive participants2019-09-15216
2018: DAVIS EXPRESS, INC. HEALTH AND WELFARE PLAN 2018 401k membership
Total participants, beginning-of-year2018-09-15222
Total number of active participants reported on line 7a of the Form 55002018-09-15224
Number of retired or separated participants receiving benefits2018-09-150
Number of other retired or separated participants entitled to future benefits2018-09-150
Total of all active and inactive participants2018-09-15224
2017: DAVIS EXPRESS, INC. HEALTH AND WELFARE PLAN 2017 401k membership
Total participants, beginning-of-year2017-09-15250
Total number of active participants reported on line 7a of the Form 55002017-09-15250
Number of retired or separated participants receiving benefits2017-09-150
Number of other retired or separated participants entitled to future benefits2017-09-150
Total of all active and inactive participants2017-09-15250
2016: DAVIS EXPRESS, INC. HEALTH AND WELFARE PLAN 2016 401k membership
Total participants, beginning-of-year2016-09-15273
Total number of active participants reported on line 7a of the Form 55002016-09-15250
Number of retired or separated participants receiving benefits2016-09-150
Number of other retired or separated participants entitled to future benefits2016-09-150
Total of all active and inactive participants2016-09-15250
2015: DAVIS EXPRESS, INC. HEALTH AND WELFARE PLAN 2015 401k membership
Total participants, beginning-of-year2015-09-15273
Total number of active participants reported on line 7a of the Form 55002015-09-15273
Number of retired or separated participants receiving benefits2015-09-150
Number of other retired or separated participants entitled to future benefits2015-09-150
Total of all active and inactive participants2015-09-15273
2014: DAVIS EXPRESS, INC. HEALTH AND WELFARE PLAN 2014 401k membership
Total participants, beginning-of-year2014-09-15290
Total number of active participants reported on line 7a of the Form 55002014-09-15273
Number of retired or separated participants receiving benefits2014-09-150
Number of other retired or separated participants entitled to future benefits2014-09-150
Total of all active and inactive participants2014-09-15273
2013: DAVIS EXPRESS, INC. HEALTH AND WELFARE PLAN 2013 401k membership
Total participants, beginning-of-year2013-09-15280
Total number of active participants reported on line 7a of the Form 55002013-09-15279
Number of retired or separated participants receiving benefits2013-09-151
Number of other retired or separated participants entitled to future benefits2013-09-150
Total of all active and inactive participants2013-09-15280
2012: DAVIS EXPRESS, INC. HEALTH AND WELFARE PLAN 2012 401k membership
Total participants, beginning-of-year2012-09-15309
Total number of active participants reported on line 7a of the Form 55002012-09-15298
Number of retired or separated participants receiving benefits2012-09-152
Number of other retired or separated participants entitled to future benefits2012-09-150
Total of all active and inactive participants2012-09-15300
2011: DAVIS EXPRESS, INC. HEALTH AND WELFARE PLAN 2011 401k membership
Total participants, beginning-of-year2011-09-15289
Total number of active participants reported on line 7a of the Form 55002011-09-15309
Number of retired or separated participants receiving benefits2011-09-152
Number of other retired or separated participants entitled to future benefits2011-09-150
Total of all active and inactive participants2011-09-15311
2010: DAVIS EXPRESS, INC. HEALTH AND WELFARE PLAN 2010 401k membership
Total participants, beginning-of-year2010-09-15240
Total number of active participants reported on line 7a of the Form 55002010-09-15296
Number of retired or separated participants receiving benefits2010-09-155
Number of other retired or separated participants entitled to future benefits2010-09-150
Total of all active and inactive participants2010-09-15301
2009: DAVIS EXPRESS, INC. HEALTH AND WELFARE PLAN 2009 401k membership
Total participants, beginning-of-year2009-09-15222
Total number of active participants reported on line 7a of the Form 55002009-09-15229
Number of retired or separated participants receiving benefits2009-09-1510
Number of other retired or separated participants entitled to future benefits2009-09-150
Total of all active and inactive participants2009-09-15239
2008: DAVIS EXPRESS, INC. HEALTH AND WELFARE PLAN 2008 401k membership
Total participants, beginning-of-year2008-09-15170
Total number of active participants reported on line 7a of the Form 55002008-09-15165
Number of retired or separated participants receiving benefits2008-09-150
Number of other retired or separated participants entitled to future benefits2008-09-150
Total of all active and inactive participants2008-09-15165
2007: DAVIS EXPRESS, INC. HEALTH AND WELFARE PLAN 2007 401k membership
Total participants, beginning-of-year2007-09-15143
Total number of active participants reported on line 7a of the Form 55002007-09-15170
Number of retired or separated participants receiving benefits2007-09-150
Number of other retired or separated participants entitled to future benefits2007-09-150
Total of all active and inactive participants2007-09-15170

Form 5500 Responses for DAVIS EXPRESS, INC. HEALTH AND WELFARE PLAN

2021: DAVIS EXPRESS, INC. HEALTH AND WELFARE PLAN 2021 form 5500 responses
2021-09-15Type of plan entitySingle employer plan
2021-09-15Submission has been amendedNo
2021-09-15This submission is the final filingNo
2021-09-15This return/report is a short plan year return/report (less than 12 months)No
2021-09-15Plan is a collectively bargained planNo
2021-09-15Plan funding arrangement – InsuranceYes
2021-09-15Plan funding arrangement – General assets of the sponsorYes
2021-09-15Plan benefit arrangement – InsuranceYes
2021-09-15Plan benefit arrangement – General assets of the sponsorYes
2020: DAVIS EXPRESS, INC. HEALTH AND WELFARE PLAN 2020 form 5500 responses
2020-09-15Type of plan entitySingle employer plan
2020-09-15Submission has been amendedNo
2020-09-15This submission is the final filingNo
2020-09-15This return/report is a short plan year return/report (less than 12 months)No
2020-09-15Plan is a collectively bargained planNo
2020-09-15Plan funding arrangement – InsuranceYes
2020-09-15Plan funding arrangement – General assets of the sponsorYes
2020-09-15Plan benefit arrangement – InsuranceYes
2020-09-15Plan benefit arrangement – General assets of the sponsorYes
2019: DAVIS EXPRESS, INC. HEALTH AND WELFARE PLAN 2019 form 5500 responses
2019-09-15Type of plan entitySingle employer plan
2019-09-15Submission has been amendedNo
2019-09-15This submission is the final filingNo
2019-09-15This return/report is a short plan year return/report (less than 12 months)No
2019-09-15Plan is a collectively bargained planNo
2019-09-15Plan funding arrangement – InsuranceYes
2019-09-15Plan funding arrangement – General assets of the sponsorYes
2019-09-15Plan benefit arrangement – InsuranceYes
2019-09-15Plan benefit arrangement – General assets of the sponsorYes
2018: DAVIS EXPRESS, INC. HEALTH AND WELFARE PLAN 2018 form 5500 responses
2018-09-15Type of plan entitySingle employer plan
2018-09-15Submission has been amendedNo
2018-09-15This submission is the final filingNo
2018-09-15This return/report is a short plan year return/report (less than 12 months)No
2018-09-15Plan is a collectively bargained planNo
2018-09-15Plan funding arrangement – InsuranceYes
2018-09-15Plan funding arrangement – General assets of the sponsorYes
2018-09-15Plan benefit arrangement – InsuranceYes
2018-09-15Plan benefit arrangement – General assets of the sponsorYes
2017: DAVIS EXPRESS, INC. HEALTH AND WELFARE PLAN 2017 form 5500 responses
2017-09-15Type of plan entitySingle employer plan
2017-09-15Submission has been amendedNo
2017-09-15This submission is the final filingNo
2017-09-15This return/report is a short plan year return/report (less than 12 months)No
2017-09-15Plan is a collectively bargained planNo
2017-09-15Plan funding arrangement – InsuranceYes
2017-09-15Plan funding arrangement – General assets of the sponsorYes
2017-09-15Plan benefit arrangement – InsuranceYes
2017-09-15Plan benefit arrangement – General assets of the sponsorYes
2016: DAVIS EXPRESS, INC. HEALTH AND WELFARE PLAN 2016 form 5500 responses
2016-09-15Type of plan entitySingle employer plan
2016-09-15Submission has been amendedNo
2016-09-15This submission is the final filingNo
2016-09-15This return/report is a short plan year return/report (less than 12 months)No
2016-09-15Plan is a collectively bargained planNo
2016-09-15Plan funding arrangement – InsuranceYes
2016-09-15Plan funding arrangement – General assets of the sponsorYes
2016-09-15Plan benefit arrangement – InsuranceYes
2016-09-15Plan benefit arrangement – General assets of the sponsorYes
2015: DAVIS EXPRESS, INC. HEALTH AND WELFARE PLAN 2015 form 5500 responses
2015-09-15Type of plan entitySingle employer plan
2015-09-15Submission has been amendedNo
2015-09-15This submission is the final filingNo
2015-09-15This return/report is a short plan year return/report (less than 12 months)No
2015-09-15Plan is a collectively bargained planNo
2015-09-15Plan funding arrangement – InsuranceYes
2015-09-15Plan funding arrangement – General assets of the sponsorYes
2015-09-15Plan benefit arrangement – InsuranceYes
2015-09-15Plan benefit arrangement – General assets of the sponsorYes
2014: DAVIS EXPRESS, INC. HEALTH AND WELFARE PLAN 2014 form 5500 responses
2014-09-15Type of plan entitySingle employer plan
2014-09-15Submission has been amendedNo
2014-09-15This submission is the final filingNo
2014-09-15This return/report is a short plan year return/report (less than 12 months)No
2014-09-15Plan is a collectively bargained planNo
2014-09-15Plan funding arrangement – InsuranceYes
2014-09-15Plan funding arrangement – General assets of the sponsorYes
2014-09-15Plan benefit arrangement – InsuranceYes
2014-09-15Plan benefit arrangement – General assets of the sponsorYes
2013: DAVIS EXPRESS, INC. HEALTH AND WELFARE PLAN 2013 form 5500 responses
2013-09-15Type of plan entitySingle employer plan
2013-09-15Submission has been amendedNo
2013-09-15This submission is the final filingNo
2013-09-15This return/report is a short plan year return/report (less than 12 months)No
2013-09-15Plan is a collectively bargained planNo
2013-09-15Plan funding arrangement – InsuranceYes
2013-09-15Plan funding arrangement – General assets of the sponsorYes
2013-09-15Plan benefit arrangement – InsuranceYes
2013-09-15Plan benefit arrangement – General assets of the sponsorYes
2012: DAVIS EXPRESS, INC. HEALTH AND WELFARE PLAN 2012 form 5500 responses
2012-09-15Type of plan entitySingle employer plan
2012-09-15Submission has been amendedNo
2012-09-15This submission is the final filingNo
2012-09-15This return/report is a short plan year return/report (less than 12 months)No
2012-09-15Plan is a collectively bargained planNo
2012-09-15Plan funding arrangement – InsuranceYes
2012-09-15Plan funding arrangement – General assets of the sponsorYes
2012-09-15Plan benefit arrangement – InsuranceYes
2012-09-15Plan benefit arrangement – General assets of the sponsorYes
2011: DAVIS EXPRESS, INC. HEALTH AND WELFARE PLAN 2011 form 5500 responses
2011-09-15Type of plan entitySingle employer plan
2011-09-15Submission has been amendedNo
2011-09-15This submission is the final filingNo
2011-09-15This return/report is a short plan year return/report (less than 12 months)No
2011-09-15Plan is a collectively bargained planNo
2011-09-15Plan funding arrangement – InsuranceYes
2011-09-15Plan funding arrangement – General assets of the sponsorYes
2011-09-15Plan benefit arrangement – InsuranceYes
2011-09-15Plan benefit arrangement – General assets of the sponsorYes
2010: DAVIS EXPRESS, INC. HEALTH AND WELFARE PLAN 2010 form 5500 responses
2010-09-15Type of plan entitySingle employer plan
2010-09-15Submission has been amendedNo
2010-09-15This submission is the final filingNo
2010-09-15This return/report is a short plan year return/report (less than 12 months)No
2010-09-15Plan is a collectively bargained planNo
2010-09-15Plan funding arrangement – General assets of the sponsorYes
2010-09-15Plan benefit arrangement – General assets of the sponsorYes
2009: DAVIS EXPRESS, INC. HEALTH AND WELFARE PLAN 2009 form 5500 responses
2009-09-15Type of plan entitySingle employer plan
2009-09-15Submission has been amendedNo
2009-09-15This submission is the final filingNo
2009-09-15This return/report is a short plan year return/report (less than 12 months)No
2009-09-15Plan is a collectively bargained planNo
2009-09-15Plan funding arrangement – General assets of the sponsorYes
2009-09-15Plan benefit arrangement – General assets of the sponsorYes
2008: DAVIS EXPRESS, INC. HEALTH AND WELFARE PLAN 2008 form 5500 responses
2008-09-15Type of plan entitySingle employer plan
2008-09-15Submission has been amendedNo
2008-09-15This submission is the final filingNo
2008-09-15This return/report is a short plan year return/report (less than 12 months)No
2008-09-15Plan is a collectively bargained planNo
2008-09-15Plan funding arrangement – General assets of the sponsorYes
2008-09-15Plan benefit arrangement – General assets of the sponsorYes
2007: DAVIS EXPRESS, INC. HEALTH AND WELFARE PLAN 2007 form 5500 responses
2007-09-15Type of plan entitySingle employer plan
2007-09-15First time form 5500 has been submittedYes
2007-09-15Submission has been amendedNo
2007-09-15This submission is the final filingNo
2007-09-15This return/report is a short plan year return/report (less than 12 months)No
2007-09-15Plan is a collectively bargained planNo
2007-09-15Plan funding arrangement – General assets of the sponsorYes
2007-09-15Plan benefit arrangement – General assets of the sponsorYes

Insurance Providers Used on plan

SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )
Policy contract number941030
Policy instance 1
Insurance contract or identification number00
Number of Individuals Covered455
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Other welfare benefits providedEMPLOYEE ASSISTANCE PROGRAM
Welfare Benefit Premiums Paid to CarrierUSD $8,598
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
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 BenefitYes
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
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
Commission paid to Insurance BrokerUSD $28,161
Insurance broker organization code?3
SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )
Policy contract number941030
Policy instance 1
Insurance contract or identification number941030
Number of Individuals Covered273
Insurance policy start date2020-09-01
Insurance policy end date2021-08-31
Total amount of commissions paid to insurance brokerUSD $26,657
Total amount of fees paid to insurance companyUSD $12,249
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 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 & DISMEMBERMENT, ACCIDENT, CRITICAL ILLNESS
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $238,594
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $26,657
Amount paid for insurance broker fees12249
Additional information about fees paid to insurance brokerBONUS
Insurance broker organization code?3
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 32395 )
Policy contract number30049940
Policy instance 4
Insurance contract or identification number30049940
Number of Individuals Covered170
Insurance policy start date2019-09-01
Insurance policy end date2020-08-31
Total amount of commissions paid to insurance brokerUSD $1,691
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 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 $18,388
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,691
Insurance broker organization code?3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract numberR0549899
Policy instance 3
Insurance contract or identification numberR0549899
Number of Individuals Covered259
Insurance policy start date2019-09-01
Insurance policy end date2020-08-31
Total amount of commissions paid to insurance brokerUSD $8,589
Total amount of fees paid to insurance companyUSD $624
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 providedACCIDENT, CRITICAL ILLNESS
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $60,717
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $8,589
Amount paid for insurance broker fees624
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION PAID
Insurance broker organization code?3
DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 )
Policy contract numberF018539
Policy instance 2
Insurance contract or identification numberF018539
Number of Individuals Covered149
Insurance policy start date2019-09-01
Insurance policy end date2020-08-31
Total amount of commissions paid to insurance brokerUSD $14,515
Total amount of fees paid to insurance companyUSD $4,727
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 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 $145,153
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $14,515
Amount paid for insurance broker fees4727
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberSGM601538
Policy instance 1
Insurance contract or identification numberSGM601538
Number of Individuals Covered233
Insurance policy start date2019-09-01
Insurance policy end date2020-08-31
Total amount of commissions paid to insurance brokerUSD $982
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 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 $51,580
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $982
Insurance broker organization code?3
DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 )
Policy contract numberF018539
Policy instance 2
Insurance contract or identification numberF018539
Number of Individuals Covered149
Insurance policy start date2018-09-15
Insurance policy end date2019-09-14
Total amount of commissions paid to insurance brokerUSD $14,416
Total amount of fees paid to insurance companyUSD $7,511
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 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 $144,151
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $14,416
Amount paid for insurance broker fees7511
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
Insurance broker organization code?3
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberSGM601538
Policy instance 1
Insurance contract or identification numberSGM601538
Number of Individuals Covered222
Insurance policy start date2018-09-15
Insurance policy end date2019-09-14
Total amount of commissions paid to insurance brokerUSD $6,165
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 $51,369
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6,165
Insurance broker organization code?3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract numberR0549899
Policy instance 3
Insurance contract or identification numberR0549899
Number of Individuals Covered222
Insurance policy start date2018-09-01
Insurance policy end date2019-08-31
Total amount of commissions paid to insurance brokerUSD $8,286
Total amount of fees paid to insurance companyUSD $646
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 providedACCIDENT AND CRITICAL ILLNESS
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $52,783
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $8,286
Amount paid for insurance broker fees646
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
Insurance broker organization code?3
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 32395 )
Policy contract number30049940
Policy instance 4
Insurance contract or identification number30049940
Number of Individuals Covered156
Insurance policy start date2018-09-01
Insurance policy end date2019-08-31
Total amount of commissions paid to insurance brokerUSD $1,732
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 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 $18,760
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,732
Insurance broker organization code?3
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 32395 )
Policy contract number30049940
Policy instance 3
Insurance contract or identification number30049940
Number of Individuals Covered164
Insurance policy start date2017-09-01
Insurance policy end date2018-08-31
Total amount of commissions paid to insurance brokerUSD $1,835
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 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 $18,348
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 )
Policy contract numberF018539
Policy instance 2
Insurance contract or identification numberF018539
Number of Individuals Covered171
Insurance policy start date2017-09-15
Insurance policy end date2018-09-14
Total amount of commissions paid to insurance brokerUSD $10,083
Total amount of fees paid to insurance companyUSD $5,421
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 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 $65,035
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberSGM601538
Policy instance 1
Insurance contract or identification numberSGM601538
Number of Individuals Covered250
Insurance policy start date2017-09-15
Insurance policy end date2018-09-14
Total amount of commissions paid to insurance brokerUSD $1,157
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 $9,642
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 32395 )
Policy contract number30049940
Policy instance 3
Insurance contract or identification number30049940
Number of Individuals Covered169
Insurance policy start date2015-09-01
Insurance policy end date2016-08-31
Total amount of commissions paid to insurance brokerUSD $2,193
Total amount of fees paid to insurance companyUSD $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 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 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 $21,932
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,193
Insurance broker organization code?3
Insurance broker nameCOTTINGHAM & BUTLER
DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 )
Policy contract numberF018539
Policy instance 2
Insurance contract or identification numberF018539
Number of Individuals Covered171
Insurance policy start date2015-09-15
Insurance policy end date2016-09-14
Total amount of commissions paid to insurance brokerUSD $11,688
Total amount of fees paid to insurance companyUSD $6,470
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 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 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 $116,878
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $11,688
Amount paid for insurance broker fees6470
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
Insurance broker organization code?3
Insurance broker nameCOTTINGHAM & BUTLER
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberSGM601538
Policy instance 1
Insurance contract or identification numberSGM601538
Number of Individuals Covered142
Insurance policy start date2015-09-15
Insurance policy end date2016-09-14
Total amount of commissions paid to insurance brokerUSD $3,406
Total amount of fees paid to insurance companyUSD $953
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 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 $46,989
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,406
Amount paid for insurance broker fees953
Additional information about fees paid to insurance brokerOVERRIDE
Insurance broker organization code?3
Insurance broker nameCOTTINGHAM & BUTLER
DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 )
Policy contract numberF018539
Policy instance 2
Insurance contract or identification numberF018539
Number of Individuals Covered210
Insurance policy start date2014-09-15
Insurance policy end date2015-09-14
Total amount of commissions paid to insurance brokerUSD $12,532
Total amount of fees paid to insurance companyUSD $193
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 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 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 $125,320
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $12,532
Amount paid for insurance broker fees193
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
Insurance broker organization code?3
Insurance broker nameCOTTINGHAM & BUTLER
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 32395 )
Policy contract number30049940
Policy instance 3
Insurance contract or identification number30049940
Number of Individuals Covered176
Insurance policy start date2014-09-01
Insurance policy end date2015-08-31
Total amount of commissions paid to insurance brokerUSD $1,968
Total amount of fees paid to insurance companyUSD $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 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
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 $19,678
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,968
Insurance broker organization code?3
Insurance broker nameCOTTINGHAM & BUTLER
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberSGM601538
Policy instance 1
Insurance contract or identification numberSGM601538
Number of Individuals Covered173
Insurance policy start date2014-09-15
Insurance policy end date2015-09-14
Total amount of commissions paid to insurance brokerUSD $4,130
Total amount of fees paid to insurance companyUSD $1,165
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 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 $57,082
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,130
Amount paid for insurance broker fees1165
Additional information about fees paid to insurance brokerOVERRIDE
Insurance broker organization code?3
Insurance broker nameCOTTINGHAM & BUTLER
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberSGM601538
Policy instance 1
Insurance contract or identification numberSGM601538
Number of Individuals Covered279
Insurance policy start date2013-09-15
Insurance policy end date2014-09-14
Total amount of commissions paid to insurance brokerUSD $4,177
Total amount of fees paid to insurance companyUSD $1,165
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 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 $57,175
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,177
Amount paid for insurance broker fees1165
Additional information about fees paid to insurance brokerOVERRIDE
Insurance broker organization code?3
Insurance broker nameCOTTINGHAM & BUTLER
DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 )
Policy contract numberF018539
Policy instance 2
Insurance contract or identification numberF018539
Number of Individuals Covered219
Insurance policy start date2013-09-15
Insurance policy end date2014-09-14
Total amount of commissions paid to insurance brokerUSD $15,652
Total amount of fees paid to insurance companyUSD $132
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 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 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 $156,378
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $15,652
Amount paid for insurance broker fees132
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
Insurance broker organization code?3
Insurance broker nameCOTTINGHAM & BUTLER
DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 )
Policy contract numberF018539
Policy instance 2
Insurance contract or identification numberF018539
Number of Individuals Covered246
Insurance policy start date2012-09-15
Insurance policy end date2013-09-14
Total amount of commissions paid to insurance brokerUSD $15,870
Total amount of fees paid to insurance companyUSD $3,024
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 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 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 $159,270
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $15,870
Amount paid for insurance broker fees3024
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
Insurance broker organization code?3
Insurance broker nameCOTTINGHAM & BUTLER
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberSGM601538
Policy instance 1
Insurance contract or identification numberSGM601538
Number of Individuals Covered298
Insurance policy start date2012-10-01
Insurance policy end date2013-09-30
Total amount of commissions paid to insurance brokerUSD $4,216
Total amount of fees paid to insurance companyUSD $1,234
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 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 $58,761
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,216
Amount paid for insurance broker fees1234
Additional information about fees paid to insurance brokerOVERRIDE
Insurance broker organization code?3
Insurance broker nameCOTTINGHAM & BUTLER
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract numberSGM601538
Policy instance 1
Insurance contract or identification numberSGM601538
Number of Individuals Covered309
Insurance policy start date2011-10-01
Insurance policy end date2012-09-30
Total amount of commissions paid to insurance brokerUSD $4,789
Total amount of fees paid to insurance companyUSD $921
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 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 $66,691
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number867101G
Policy instance 2
Insurance contract or identification number867101G
Number of Individuals Covered252
Insurance policy start date2011-10-01
Insurance policy end date2012-09-30
Total amount of commissions paid to insurance brokerUSD $10,990
Total amount of fees paid to insurance companyUSD $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 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 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 $177,583
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No

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