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INFINITE ENERGY, INC. HEALTH & WELFARE BENEFIT PLAN 401k Plan overview

Plan NameINFINITE ENERGY, INC. HEALTH & WELFARE BENEFIT PLAN
Plan identification number 501

INFINITE ENERGY, INC. HEALTH & WELFARE BENEFIT PLAN Benefits

401k Plan TypeWelfare Benefit
Plan Features/Benefits
  • Health (other than dental or vision)
  • Life insurance
  • Dental
  • Vision
  • Temporary disability (accident and sickness)
  • Long-term disability cover
  • Other welfare benefit cover

401k Sponsoring company profile

INFINITE ENERGY, INC. has sponsored the creation of one or more 401k plans.

Company Name:INFINITE ENERGY, INC.
Employer identification number (EIN):593244997
NAIC Classification:221210
NAIC Description:Natural Gas Distribution

Additional information about INFINITE ENERGY, INC.

Jurisdiction of Incorporation: Florida Department of State Division of Corporations
Incorporation Date: 1994-05-09
Company Identification Number: P94000035390
Legal Registered Office Address: 7001 SW 24TH AVE

GAINESVILLE

32607

More information about INFINITE ENERGY, INC.

Form 5500 Filing Information

Submission information for form 5500 for 401k plan INFINITE ENERGY, INC. HEALTH & WELFARE BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5012021-06-01
5012020-06-01
5012019-06-01
5012018-06-01
5012017-06-01RICHARD BLASER
5012016-06-01RICHARD BLASER
5012015-06-01RICHARD BLASER
5012014-06-01RICHARD BLASER
5012013-06-01RICHARD BLASER
5012012-06-01RICHARD BLASER
5012011-06-01LISA M THORNE
5012010-06-01GENE ROINICK
5012009-06-01GENE ROINICK

Plan Statistics for INFINITE ENERGY, INC. HEALTH & WELFARE BENEFIT PLAN

401k plan membership statisitcs for INFINITE ENERGY, INC. HEALTH & WELFARE BENEFIT PLAN

Measure Date Value
2021: INFINITE ENERGY, INC. HEALTH & WELFARE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year2021-06-01127
Total number of active participants reported on line 7a of the Form 55002021-06-010
Number of retired or separated participants receiving benefits2021-06-010
Number of other retired or separated participants entitled to future benefits2021-06-010
Total of all active and inactive participants2021-06-010
2020: INFINITE ENERGY, INC. HEALTH & WELFARE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year2020-06-01284
Total number of active participants reported on line 7a of the Form 55002020-06-01170
Number of retired or separated participants receiving benefits2020-06-019
Number of other retired or separated participants entitled to future benefits2020-06-010
Total of all active and inactive participants2020-06-01179
2019: INFINITE ENERGY, INC. HEALTH & WELFARE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year2019-06-01288
Total number of active participants reported on line 7a of the Form 55002019-06-01281
Number of retired or separated participants receiving benefits2019-06-013
Number of other retired or separated participants entitled to future benefits2019-06-010
Total of all active and inactive participants2019-06-01284
2018: INFINITE ENERGY, INC. HEALTH & WELFARE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year2018-06-01283
Total number of active participants reported on line 7a of the Form 55002018-06-01289
Number of retired or separated participants receiving benefits2018-06-012
Number of other retired or separated participants entitled to future benefits2018-06-010
Total of all active and inactive participants2018-06-01291
2017: INFINITE ENERGY, INC. HEALTH & WELFARE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year2017-06-01298
Total number of active participants reported on line 7a of the Form 55002017-06-01286
Number of retired or separated participants receiving benefits2017-06-010
Number of other retired or separated participants entitled to future benefits2017-06-010
Total of all active and inactive participants2017-06-01286
2016: INFINITE ENERGY, INC. HEALTH & WELFARE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year2016-06-01319
Total number of active participants reported on line 7a of the Form 55002016-06-01306
Number of retired or separated participants receiving benefits2016-06-014
Number of other retired or separated participants entitled to future benefits2016-06-010
Total of all active and inactive participants2016-06-01310
2015: INFINITE ENERGY, INC. HEALTH & WELFARE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year2015-06-01292
Total number of active participants reported on line 7a of the Form 55002015-06-01285
Number of retired or separated participants receiving benefits2015-06-011
Number of other retired or separated participants entitled to future benefits2015-06-010
Total of all active and inactive participants2015-06-01286
2014: INFINITE ENERGY, INC. HEALTH & WELFARE BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year2014-06-01345
Total number of active participants reported on line 7a of the Form 55002014-06-01313
Number of retired or separated participants receiving benefits2014-06-012
Number of other retired or separated participants entitled to future benefits2014-06-010
Total of all active and inactive participants2014-06-01315
2013: INFINITE ENERGY, INC. HEALTH & WELFARE BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year2013-06-01338
Total number of active participants reported on line 7a of the Form 55002013-06-01345
Number of retired or separated participants receiving benefits2013-06-012
Number of other retired or separated participants entitled to future benefits2013-06-010
Total of all active and inactive participants2013-06-01347
2012: INFINITE ENERGY, INC. HEALTH & WELFARE BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year2012-06-01331
Total number of active participants reported on line 7a of the Form 55002012-06-01334
Number of retired or separated participants receiving benefits2012-06-014
Number of other retired or separated participants entitled to future benefits2012-06-010
Total of all active and inactive participants2012-06-01338
2011: INFINITE ENERGY, INC. HEALTH & WELFARE BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year2011-06-01344
Total number of active participants reported on line 7a of the Form 55002011-06-01327
Number of retired or separated participants receiving benefits2011-06-014
Number of other retired or separated participants entitled to future benefits2011-06-010
Total of all active and inactive participants2011-06-01331
2010: INFINITE ENERGY, INC. HEALTH & WELFARE BENEFIT PLAN 2010 401k membership
Total participants, beginning-of-year2010-06-01330
Total number of active participants reported on line 7a of the Form 55002010-06-01337
Number of retired or separated participants receiving benefits2010-06-017
Number of other retired or separated participants entitled to future benefits2010-06-010
Total of all active and inactive participants2010-06-01344
2009: INFINITE ENERGY, INC. HEALTH & WELFARE BENEFIT PLAN 2009 401k membership
Total participants, beginning-of-year2009-06-01299
Total number of active participants reported on line 7a of the Form 55002009-06-01322
Number of retired or separated participants receiving benefits2009-06-018
Number of other retired or separated participants entitled to future benefits2009-06-010
Total of all active and inactive participants2009-06-01330

Form 5500 Responses for INFINITE ENERGY, INC. HEALTH & WELFARE BENEFIT PLAN

2021: INFINITE ENERGY, INC. HEALTH & WELFARE BENEFIT PLAN 2021 form 5500 responses
2021-06-01Type of plan entitySingle employer plan
2021-06-01Submission has been amendedNo
2021-06-01This submission is the final filingYes
2021-06-01This return/report is a short plan year return/report (less than 12 months)Yes
2021-06-01Plan is a collectively bargained planNo
2021-06-01Plan funding arrangement – InsuranceYes
2021-06-01Plan funding arrangement – General assets of the sponsorYes
2021-06-01Plan benefit arrangement – InsuranceYes
2021-06-01Plan benefit arrangement – General assets of the sponsorYes
2020: INFINITE ENERGY, INC. HEALTH & WELFARE BENEFIT PLAN 2020 form 5500 responses
2020-06-01Type of plan entitySingle employer plan
2020-06-01Submission has been amendedNo
2020-06-01This submission is the final filingNo
2020-06-01This return/report is a short plan year return/report (less than 12 months)No
2020-06-01Plan is a collectively bargained planNo
2020-06-01Plan funding arrangement – InsuranceYes
2020-06-01Plan funding arrangement – General assets of the sponsorYes
2020-06-01Plan benefit arrangement – InsuranceYes
2020-06-01Plan benefit arrangement – General assets of the sponsorYes
2019: INFINITE ENERGY, INC. HEALTH & WELFARE BENEFIT PLAN 2019 form 5500 responses
2019-06-01Type of plan entitySingle employer plan
2019-06-01Submission has been amendedNo
2019-06-01This submission is the final filingNo
2019-06-01This return/report is a short plan year return/report (less than 12 months)No
2019-06-01Plan is a collectively bargained planNo
2019-06-01Plan funding arrangement – InsuranceYes
2019-06-01Plan funding arrangement – General assets of the sponsorYes
2019-06-01Plan benefit arrangement – InsuranceYes
2019-06-01Plan benefit arrangement – General assets of the sponsorYes
2018: INFINITE ENERGY, INC. HEALTH & WELFARE BENEFIT PLAN 2018 form 5500 responses
2018-06-01Type of plan entitySingle employer plan
2018-06-01Submission has been amendedNo
2018-06-01This submission is the final filingNo
2018-06-01This return/report is a short plan year return/report (less than 12 months)No
2018-06-01Plan is a collectively bargained planNo
2018-06-01Plan funding arrangement – InsuranceYes
2018-06-01Plan funding arrangement – General assets of the sponsorYes
2018-06-01Plan benefit arrangement – InsuranceYes
2018-06-01Plan benefit arrangement – General assets of the sponsorYes
2017: INFINITE ENERGY, INC. HEALTH & WELFARE BENEFIT PLAN 2017 form 5500 responses
2017-06-01Type of plan entitySingle employer plan
2017-06-01Submission has been amendedNo
2017-06-01This submission is the final filingNo
2017-06-01This return/report is a short plan year return/report (less than 12 months)No
2017-06-01Plan is a collectively bargained planNo
2017-06-01Plan funding arrangement – InsuranceYes
2017-06-01Plan funding arrangement – General assets of the sponsorYes
2017-06-01Plan benefit arrangement – InsuranceYes
2017-06-01Plan benefit arrangement – General assets of the sponsorYes
2016: INFINITE ENERGY, INC. HEALTH & WELFARE BENEFIT PLAN 2016 form 5500 responses
2016-06-01Type of plan entitySingle employer plan
2016-06-01Submission has been amendedNo
2016-06-01This submission is the final filingNo
2016-06-01This return/report is a short plan year return/report (less than 12 months)No
2016-06-01Plan is a collectively bargained planNo
2016-06-01Plan funding arrangement – InsuranceYes
2016-06-01Plan funding arrangement – General assets of the sponsorYes
2016-06-01Plan benefit arrangement – InsuranceYes
2016-06-01Plan benefit arrangement – General assets of the sponsorYes
2015: INFINITE ENERGY, INC. HEALTH & WELFARE BENEFIT PLAN 2015 form 5500 responses
2015-06-01Type of plan entitySingle employer plan
2015-06-01Submission has been amendedNo
2015-06-01This submission is the final filingNo
2015-06-01This return/report is a short plan year return/report (less than 12 months)No
2015-06-01Plan is a collectively bargained planNo
2015-06-01Plan funding arrangement – InsuranceYes
2015-06-01Plan funding arrangement – General assets of the sponsorYes
2015-06-01Plan benefit arrangement – InsuranceYes
2015-06-01Plan benefit arrangement – General assets of the sponsorYes
2014: INFINITE ENERGY, INC. HEALTH & WELFARE BENEFIT PLAN 2014 form 5500 responses
2014-06-01Type of plan entitySingle employer plan
2014-06-01Submission has been amendedNo
2014-06-01This submission is the final filingNo
2014-06-01This return/report is a short plan year return/report (less than 12 months)No
2014-06-01Plan is a collectively bargained planNo
2014-06-01Plan funding arrangement – InsuranceYes
2014-06-01Plan funding arrangement – General assets of the sponsorYes
2014-06-01Plan benefit arrangement – InsuranceYes
2014-06-01Plan benefit arrangement – General assets of the sponsorYes
2013: INFINITE ENERGY, INC. HEALTH & WELFARE BENEFIT PLAN 2013 form 5500 responses
2013-06-01Type of plan entitySingle employer plan
2013-06-01Submission has been amendedNo
2013-06-01This submission is the final filingNo
2013-06-01This return/report is a short plan year return/report (less than 12 months)No
2013-06-01Plan is a collectively bargained planNo
2013-06-01Plan funding arrangement – InsuranceYes
2013-06-01Plan funding arrangement – General assets of the sponsorYes
2013-06-01Plan benefit arrangement – InsuranceYes
2013-06-01Plan benefit arrangement – General assets of the sponsorYes
2012: INFINITE ENERGY, INC. HEALTH & WELFARE BENEFIT PLAN 2012 form 5500 responses
2012-06-01Type of plan entitySingle employer plan
2012-06-01Submission has been amendedNo
2012-06-01This submission is the final filingNo
2012-06-01This return/report is a short plan year return/report (less than 12 months)No
2012-06-01Plan is a collectively bargained planNo
2012-06-01Plan funding arrangement – InsuranceYes
2012-06-01Plan funding arrangement – General assets of the sponsorYes
2012-06-01Plan benefit arrangement – InsuranceYes
2012-06-01Plan benefit arrangement – General assets of the sponsorYes
2011: INFINITE ENERGY, INC. HEALTH & WELFARE BENEFIT PLAN 2011 form 5500 responses
2011-06-01Type of plan entitySingle employer plan
2011-06-01Submission has been amendedNo
2011-06-01This submission is the final filingNo
2011-06-01This return/report is a short plan year return/report (less than 12 months)No
2011-06-01Plan is a collectively bargained planNo
2011-06-01Plan funding arrangement – InsuranceYes
2011-06-01Plan funding arrangement – General assets of the sponsorYes
2011-06-01Plan benefit arrangement – InsuranceYes
2011-06-01Plan benefit arrangement – General assets of the sponsorYes
2010: INFINITE ENERGY, INC. HEALTH & WELFARE BENEFIT PLAN 2010 form 5500 responses
2010-06-01Type of plan entitySingle employer plan
2010-06-01Submission has been amendedNo
2010-06-01This submission is the final filingNo
2010-06-01This return/report is a short plan year return/report (less than 12 months)No
2010-06-01Plan is a collectively bargained planNo
2010-06-01Plan funding arrangement – InsuranceYes
2010-06-01Plan funding arrangement – General assets of the sponsorYes
2010-06-01Plan benefit arrangement – InsuranceYes
2010-06-01Plan benefit arrangement – General assets of the sponsorYes
2009: INFINITE ENERGY, INC. HEALTH & WELFARE BENEFIT PLAN 2009 form 5500 responses
2009-06-01Type of plan entitySingle employer plan
2009-06-01Submission has been amendedNo
2009-06-01This submission is the final filingNo
2009-06-01This return/report is a short plan year return/report (less than 12 months)No
2009-06-01Plan is a collectively bargained planNo
2009-06-01Plan funding arrangement – InsuranceYes
2009-06-01Plan funding arrangement – General assets of the sponsorYes
2009-06-01Plan benefit arrangement – InsuranceYes
2009-06-01Plan benefit arrangement – General assets of the sponsorYes

Insurance Providers Used on plan

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberG000B2FM
Policy instance 3
Insurance contract or identification numberG000B2FM
Number of Individuals Covered4
Insurance policy start date2021-06-01
Insurance policy end date2021-10-31
Total amount of commissions paid to insurance brokerUSD $1,153
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits 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 $10,068
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,153
Insurance broker organization code?3
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number10061951001
Policy instance 2
Insurance contract or identification number10061951001
Number of Individuals Covered2
Insurance policy start date2021-06-01
Insurance policy end date2021-10-31
Total amount of commissions paid to insurance brokerUSD $266
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 $1,613
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $266
Insurance broker organization code?3
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number00500036
Policy instance 1
Insurance contract or identification number00500036
Number of Individuals Covered10
Insurance policy start date2021-06-01
Insurance policy end date2021-10-31
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating 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 BenefitYes
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 $1,234
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number00500036
Policy instance 1
Insurance contract or identification number00500036
Number of Individuals Covered144
Insurance policy start date2020-06-01
Insurance policy end date2021-05-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $1,067
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 BenefitYes
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 $11,504
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Amount paid for insurance broker fees1067
Additional information about fees paid to insurance brokerFEES PAID
Insurance broker organization code?3
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number10061951001
Policy instance 2
Insurance contract or identification number10061951001
Number of Individuals Covered306
Insurance policy start date2020-06-01
Insurance policy end date2021-05-31
Total amount of commissions paid to insurance brokerUSD $2,024
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 $18,668
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,024
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberG000B2FM
Policy instance 3
Insurance contract or identification numberG000B2FM
Number of Individuals Covered134
Insurance policy start date2020-06-01
Insurance policy end date2021-05-31
Total amount of commissions paid to insurance brokerUSD $15,851
Total amount of fees paid to insurance companyUSD $9,094
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits 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 $146,301
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $15,851
Amount paid for insurance broker fees9094
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )
Policy contract numberV5749
Policy instance 4
Insurance contract or identification numberV5749
Number of Individuals Covered23
Insurance policy start date2020-06-01
Insurance policy end date2021-05-31
Total amount of commissions paid to insurance brokerUSD $2,143
Total amount of fees paid to insurance companyUSD $114
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 providedSUPPLEMENTAL BENEFITS
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 $22,794
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,143
Amount paid for insurance broker fees114
Additional information about fees paid to insurance brokerFEES PAID
Insurance broker organization code?3
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number00500036
Policy instance 1
Insurance contract or identification number00500036
Number of Individuals Covered275
Insurance policy start date2019-06-01
Insurance policy end date2020-05-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $1,039
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 BenefitYes
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 $17,013
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Amount paid for insurance broker fees1039
Additional information about fees paid to insurance brokerADDITIONAL BROKER COMPENSATION
Insurance broker organization code?3
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number10061951001
Policy instance 2
Insurance contract or identification number10061951001
Number of Individuals Covered313
Insurance policy start date2019-06-01
Insurance policy end date2020-05-31
Total amount of commissions paid to insurance brokerUSD $2,011
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 $18,334
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,011
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberG000B2FM
Policy instance 3
Insurance contract or identification numberG000B2FM
Number of Individuals Covered289
Insurance policy start date2019-06-01
Insurance policy end date2020-05-31
Total amount of commissions paid to insurance brokerUSD $17,326
Total amount of fees paid to insurance companyUSD $16,916
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits 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 $160,294
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $17,326
Amount paid for insurance broker fees9740
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )
Policy contract numberV5749
Policy instance 4
Insurance contract or identification numberV5749
Number of Individuals Covered30
Insurance policy start date2019-06-01
Insurance policy end date2020-05-31
Total amount of commissions paid to insurance brokerUSD $3,133
Total amount of fees paid to insurance companyUSD $51
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 providedSUPPLEMENTAL BENEFITS
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 $24,519
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,133
Amount paid for insurance broker fees51
Additional information about fees paid to insurance brokerFEES PAID
Insurance broker organization code?3
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number00500036
Policy instance 1
Insurance contract or identification number00500036
Number of Individuals Covered285
Insurance policy start date2018-06-01
Insurance policy end date2019-05-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $959
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 BenefitYes
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 $12,832
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Amount paid for insurance broker fees959
Additional information about fees paid to insurance brokerADDITIONAL BROKER COMPENSATION
Insurance broker organization code?3
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number10061951001
Policy instance 2
Insurance contract or identification number10061951001
Number of Individuals Covered324
Insurance policy start date2018-06-01
Insurance policy end date2019-05-31
Total amount of commissions paid to insurance brokerUSD $2,425
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 $21,202
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,425
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberG000B2FM
Policy instance 3
Insurance contract or identification numberG000B2FM
Number of Individuals Covered287
Insurance policy start date2018-06-01
Insurance policy end date2019-05-31
Total amount of commissions paid to insurance brokerUSD $17,855
Total amount of fees paid to insurance companyUSD $19,425
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits 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 $164,758
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $17,855
Amount paid for insurance broker fees7350
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberG000B2FM
Policy instance 3
Insurance contract or identification numberG000B2FM
Number of Individuals Covered115
Insurance policy start date2017-06-01
Insurance policy end date2018-05-31
Total amount of commissions paid to insurance brokerUSD $17,662
Total amount of fees paid to insurance companyUSD $17,802
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits 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 $105,936
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $17,662
Amount paid for insurance broker fees5847
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
Insurance broker nameNATIONAL BENEFIT CENTER LLC
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number10061951001
Policy instance 2
Insurance contract or identification number10061951001
Number of Individuals Covered291
Insurance policy start date2017-06-01
Insurance policy end date2018-05-31
Total amount of commissions paid to insurance brokerUSD $1,889
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 $18,895
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,889
Insurance broker organization code?3
Insurance broker nameBOUCHARD INSURNACE
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number00500036
Policy instance 1
Insurance contract or identification number00500036
Number of Individuals Covered277
Insurance policy start date2017-06-01
Insurance policy end date2018-05-31
Total amount of commissions paid to insurance brokerUSD $73
Total amount of fees paid to insurance companyUSD $951
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 BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
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 $14,179
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $0
Amount paid for insurance broker fees951
Additional information about fees paid to insurance brokerADDITIONAL BROKER COMPENSATION
Insurance broker organization code?3
Insurance broker nameNATIONAL BENEFIT CENTER LLC
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number00500036
Policy instance 1
Insurance contract or identification number00500036
Number of Individuals Covered309
Insurance policy start date2015-06-01
Insurance policy end date2016-05-31
Total amount of commissions paid to insurance brokerUSD $16,782
Total amount of fees paid to insurance companyUSD $7,232
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 BenefitYes
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
Welfare Benefit Premiums Paid to CarrierUSD $167,976
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $14,550
Amount paid for insurance broker fees7232
Additional information about fees paid to insurance brokerADDITIONAL BROKER COMPENSATION
Insurance broker organization code?3
Insurance broker nameNATIONAL BENEFIT CENTER LLC
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number302686
Policy instance 1
Insurance contract or identification number302686
Number of Individuals Covered313
Insurance policy start date2014-06-01
Insurance policy end date2015-05-31
Total amount of commissions paid to insurance brokerUSD $7,808
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 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 $68,574
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $7,808
Insurance broker organization code?3
Insurance broker nameBOUCHARD INSURANCE AGENCY
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number00500036
Policy instance 2
Insurance contract or identification number00500036
Number of Individuals Covered316
Insurance policy start date2014-06-01
Insurance policy end date2015-05-31
Total amount of commissions paid to insurance brokerUSD $17,920
Total amount of fees paid to insurance companyUSD $5,224
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 BenefitYes
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
Welfare Benefit Premiums Paid to CarrierUSD $160,508
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $13,529
Amount paid for insurance broker fees5224
Additional information about fees paid to insurance brokerADDITIONAL BROKER COMPENSATION
Insurance broker organization code?3
Insurance broker nameNATIONAL BENEFIT CENTER LLC
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number9846569
Policy instance 3
Insurance contract or identification number9846569
Number of Individuals Covered250
Insurance policy start date2013-06-01
Insurance policy end date2014-05-31
Total amount of commissions paid to insurance brokerUSD $2,857
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 $15,490
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,423
Insurance broker organization code?3
Insurance broker nameADAMS BENEFIT CORP.
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number302686
Policy instance 1
Insurance contract or identification number302686
Number of Individuals Covered345
Insurance policy start date2013-06-01
Insurance policy end date2014-05-31
Total amount of commissions paid to insurance brokerUSD $2,789
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 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 $45,652
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,789
Insurance broker organization code?3
Insurance broker nameROGER BOUCHARD
UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 )
Policy contract number5452567
Policy instance 2
Insurance contract or identification number5452567
Number of Individuals Covered331
Insurance policy start date2013-06-01
Insurance policy end date2014-05-31
Total amount of commissions paid to insurance brokerUSD $7,646
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 $90,525
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $7,646
Insurance broker organization code?3
Insurance broker nameROGER BOUCHARD INSURANCE INC
UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 )
Policy contract number5452567
Policy instance 2
Insurance contract or identification number5452567
Number of Individuals Covered332
Insurance policy start date2012-06-01
Insurance policy end date2013-05-31
Total amount of commissions paid to insurance brokerUSD $6,299
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 $76,990
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6,299
Insurance broker organization code?3
Insurance broker nameADAMS BENEFIT CORPORATION
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number9846569
Policy instance 3
Insurance contract or identification number9846569
Number of Individuals Covered163
Insurance policy start date2012-06-01
Insurance policy end date2013-05-31
Total amount of commissions paid to insurance brokerUSD $1,238
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 $6,879
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,238
Insurance broker organization code?3
Insurance broker nameADAMS BENEFIT CORPORATION
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number302686
Policy instance 1
Insurance contract or identification number302686
Number of Individuals Covered334
Insurance policy start date2012-06-01
Insurance policy end date2013-05-31
Total amount of commissions paid to insurance brokerUSD $5,331
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 BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&D, DEPENDENT LIFE, SUPPLEMENTAL LIFE
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $47,408
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,331
Insurance broker organization code?3
Insurance broker nameADAMS BENEFIT CORPORATION
EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )
Policy contract number9846569
Policy instance 3
Insurance contract or identification number9846569
Number of Individuals Covered324
Insurance policy start date2011-06-01
Insurance policy end date2012-05-31
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number302686
Policy instance 2
Insurance contract or identification number302686
Number of Individuals Covered329
Insurance policy start date2011-06-01
Insurance policy end date2012-05-31
Total amount of commissions paid to insurance brokerUSD $6,696
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 BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&D, DEPENDENT LIFE, SUPPLEMENTAL LIFE
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $48,813
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 )
Policy contract number5452567
Policy instance 1
Insurance contract or identification number5452567
Number of Individuals Covered332
Insurance policy start date2011-06-01
Insurance policy end date2012-05-31
Total amount of commissions paid to insurance brokerUSD $5,814
Total amount of fees paid to insurance companyUSD $2,166
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 $70,949
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 )
Policy contract number5452567
Policy instance 1
Insurance contract or identification number5452567
Number of Individuals Covered332
Insurance policy start date2010-06-01
Insurance policy end date2011-05-31
Total amount of commissions paid to insurance brokerUSD $5,814
Total amount of fees paid to insurance companyUSD $2,166
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 $70,949
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number302686
Policy instance 2
Insurance contract or identification number302686
Number of Individuals Covered329
Insurance policy start date2010-06-01
Insurance policy end date2011-05-31
Total amount of commissions paid to insurance brokerUSD $6,696
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 BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&D, DEPENDENT LIFE, SUPPLEMENTAL LIFE
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $48,813
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No

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