NEWCOMB OIL CO., LLC has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan NEWCOMB OIL CO., LLC EMPLOYEE BENEFIT PLAN
| Measure | Date | Value |
|---|
| 2022: NEWCOMB OIL CO., LLC EMPLOYEE BENEFIT PLAN 2022 401k membership |
|---|
| Total participants, beginning-of-year | 2022-10-01 | 648 |
| Total number of active participants reported on line 7a of the Form 5500 | 2022-10-01 | 647 |
| Number of retired or separated participants receiving benefits | 2022-10-01 | 1 |
| Number of other retired or separated participants entitled to future benefits | 2022-10-01 | 0 |
| Total of all active and inactive participants | 2022-10-01 | 648 |
| 2021: NEWCOMB OIL CO., LLC EMPLOYEE BENEFIT PLAN 2021 401k membership |
|---|
| Total participants, beginning-of-year | 2021-10-01 | 604 |
| Total number of active participants reported on line 7a of the Form 5500 | 2021-10-01 | 643 |
| Number of retired or separated participants receiving benefits | 2021-10-01 | 4 |
| Number of other retired or separated participants entitled to future benefits | 2021-10-01 | 0 |
| Total of all active and inactive participants | 2021-10-01 | 647 |
| 2020: NEWCOMB OIL CO., LLC EMPLOYEE BENEFIT PLAN 2020 401k membership |
|---|
| Total participants, beginning-of-year | 2020-10-01 | 631 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-10-01 | 603 |
| Number of retired or separated participants receiving benefits | 2020-10-01 | 1 |
| Number of other retired or separated participants entitled to future benefits | 2020-10-01 | 0 |
| Total of all active and inactive participants | 2020-10-01 | 604 |
| 2019: NEWCOMB OIL CO., LLC EMPLOYEE BENEFIT PLAN 2019 401k membership |
|---|
| Total participants, beginning-of-year | 2019-10-01 | 562 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-10-01 | 619 |
| Number of retired or separated participants receiving benefits | 2019-10-01 | 3 |
| Number of other retired or separated participants entitled to future benefits | 2019-10-01 | 0 |
| Total of all active and inactive participants | 2019-10-01 | 622 |
| 2018: NEWCOMB OIL CO., LLC EMPLOYEE BENEFIT PLAN 2018 401k membership |
|---|
| Total participants, beginning-of-year | 2018-10-01 | 509 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-10-01 | 558 |
| Number of retired or separated participants receiving benefits | 2018-10-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2018-10-01 | 0 |
| Total of all active and inactive participants | 2018-10-01 | 558 |
| 2017: NEWCOMB OIL CO., LLC EMPLOYEE BENEFIT PLAN 2017 401k membership |
|---|
| Total participants, beginning-of-year | 2017-10-01 | 498 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-10-01 | 503 |
| Number of retired or separated participants receiving benefits | 2017-10-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2017-10-01 | 0 |
| Total of all active and inactive participants | 2017-10-01 | 503 |
| 2016: NEWCOMB OIL CO., LLC EMPLOYEE BENEFIT PLAN 2016 401k membership |
|---|
| Total participants, beginning-of-year | 2016-10-01 | 441 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-10-01 | 497 |
| Number of retired or separated participants receiving benefits | 2016-10-01 | 1 |
| Number of other retired or separated participants entitled to future benefits | 2016-10-01 | 0 |
| Total of all active and inactive participants | 2016-10-01 | 498 |
| 2015: NEWCOMB OIL CO., LLC EMPLOYEE BENEFIT PLAN 2015 401k membership |
|---|
| Total participants, beginning-of-year | 2015-10-01 | 471 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-10-01 | 438 |
| Number of retired or separated participants receiving benefits | 2015-10-01 | 3 |
| Total of all active and inactive participants | 2015-10-01 | 441 |
| 2014: NEWCOMB OIL CO., LLC EMPLOYEE BENEFIT PLAN 2014 401k membership |
|---|
| Total participants, beginning-of-year | 2014-10-01 | 385 |
| Total number of active participants reported on line 7a of the Form 5500 | 2014-10-01 | 469 |
| Number of retired or separated participants receiving benefits | 2014-10-01 | 2 |
| Number of other retired or separated participants entitled to future benefits | 2014-10-01 | 0 |
| Total of all active and inactive participants | 2014-10-01 | 471 |
| 2013: NEWCOMB OIL CO., LLC EMPLOYEE BENEFIT PLAN 2013 401k membership |
|---|
| Total participants, beginning-of-year | 2013-10-01 | 394 |
| Total number of active participants reported on line 7a of the Form 5500 | 2013-10-01 | 397 |
| Number of retired or separated participants receiving benefits | 2013-10-01 | 0 |
| Total of all active and inactive participants | 2013-10-01 | 397 |
| 2012: NEWCOMB OIL CO., LLC EMPLOYEE BENEFIT PLAN 2012 401k membership |
|---|
| Total participants, beginning-of-year | 2012-10-01 | 440 |
| Total number of active participants reported on line 7a of the Form 5500 | 2012-10-01 | 395 |
| Number of retired or separated participants receiving benefits | 2012-10-01 | 4 |
| Number of other retired or separated participants entitled to future benefits | 2012-10-01 | 0 |
| Total of all active and inactive participants | 2012-10-01 | 399 |
| 2011: NEWCOMB OIL CO., LLC EMPLOYEE BENEFIT PLAN 2011 401k membership |
|---|
| Total participants, beginning-of-year | 2011-10-01 | 397 |
| Total number of active participants reported on line 7a of the Form 5500 | 2011-10-01 | 388 |
| Number of retired or separated participants receiving benefits | 2011-10-01 | 5 |
| Number of other retired or separated participants entitled to future benefits | 2011-10-01 | 0 |
| Total of all active and inactive participants | 2011-10-01 | 393 |
| 2010: NEWCOMB OIL CO., LLC EMPLOYEE BENEFIT PLAN 2010 401k membership |
|---|
| Total participants, beginning-of-year | 2010-10-01 | 390 |
| Total number of active participants reported on line 7a of the Form 5500 | 2010-10-01 | 396 |
| Number of retired or separated participants receiving benefits | 2010-10-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2010-10-01 | 3 |
| Total of all active and inactive participants | 2010-10-01 | 399 |
| 2009: NEWCOMB OIL CO., LLC EMPLOYEE BENEFIT PLAN 2009 401k membership |
|---|
| Total participants, beginning-of-year | 2009-10-01 | 397 |
| Total number of active participants reported on line 7a of the Form 5500 | 2009-10-01 | 393 |
| Number of retired or separated participants receiving benefits | 2009-10-01 | 4 |
| Number of other retired or separated participants entitled to future benefits | 2009-10-01 | 0 |
| Total of all active and inactive participants | 2009-10-01 | 397 |
| Total participants | 2009-10-01 | 0 |
| 2022: NEWCOMB OIL CO., LLC EMPLOYEE BENEFIT PLAN 2022 form 5500 responses |
|---|
| 2022-10-01 | Type of plan entity | Single employer plan |
| 2022-10-01 | Submission has been amended | No |
| 2022-10-01 | This submission is the final filing | No |
| 2022-10-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2022-10-01 | Plan is a collectively bargained plan | No |
| 2022-10-01 | Plan funding arrangement – Insurance | Yes |
| 2022-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2022-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2022-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2021: NEWCOMB OIL CO., LLC EMPLOYEE BENEFIT PLAN 2021 form 5500 responses |
|---|
| 2021-10-01 | Type of plan entity | Single employer plan |
| 2021-10-01 | Submission has been amended | No |
| 2021-10-01 | This submission is the final filing | No |
| 2021-10-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2021-10-01 | Plan is a collectively bargained plan | No |
| 2021-10-01 | Plan funding arrangement – Insurance | Yes |
| 2021-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2021-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2021-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2020: NEWCOMB OIL CO., LLC EMPLOYEE BENEFIT PLAN 2020 form 5500 responses |
|---|
| 2020-10-01 | Type of plan entity | Single employer plan |
| 2020-10-01 | Submission has been amended | No |
| 2020-10-01 | This submission is the final filing | No |
| 2020-10-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2020-10-01 | Plan is a collectively bargained plan | No |
| 2020-10-01 | Plan funding arrangement – Insurance | Yes |
| 2020-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2020-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2020-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2019: NEWCOMB OIL CO., LLC EMPLOYEE BENEFIT PLAN 2019 form 5500 responses |
|---|
| 2019-10-01 | Type of plan entity | Single employer plan |
| 2019-10-01 | Submission has been amended | No |
| 2019-10-01 | This submission is the final filing | No |
| 2019-10-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2019-10-01 | Plan is a collectively bargained plan | No |
| 2019-10-01 | Plan funding arrangement – Insurance | Yes |
| 2019-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2019-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2019-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2018: NEWCOMB OIL CO., LLC EMPLOYEE BENEFIT PLAN 2018 form 5500 responses |
|---|
| 2018-10-01 | Type of plan entity | Single employer plan |
| 2018-10-01 | Submission has been amended | No |
| 2018-10-01 | This submission is the final filing | No |
| 2018-10-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2018-10-01 | Plan is a collectively bargained plan | No |
| 2018-10-01 | Plan funding arrangement – Insurance | Yes |
| 2018-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2018-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2018-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2017: NEWCOMB OIL CO., LLC EMPLOYEE BENEFIT PLAN 2017 form 5500 responses |
|---|
| 2017-10-01 | Type of plan entity | Single employer plan |
| 2017-10-01 | Submission has been amended | No |
| 2017-10-01 | This submission is the final filing | No |
| 2017-10-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2017-10-01 | Plan is a collectively bargained plan | No |
| 2017-10-01 | Plan funding arrangement – Insurance | Yes |
| 2017-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2017-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2017-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2016: NEWCOMB OIL CO., LLC EMPLOYEE BENEFIT PLAN 2016 form 5500 responses |
|---|
| 2016-10-01 | Type of plan entity | Single employer plan |
| 2016-10-01 | Submission has been amended | No |
| 2016-10-01 | This submission is the final filing | No |
| 2016-10-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2016-10-01 | Plan is a collectively bargained plan | No |
| 2016-10-01 | Plan funding arrangement – Insurance | Yes |
| 2016-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2016-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2016-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2015: NEWCOMB OIL CO., LLC EMPLOYEE BENEFIT PLAN 2015 form 5500 responses |
|---|
| 2015-10-01 | Type of plan entity | Single employer plan |
| 2015-10-01 | Submission has been amended | No |
| 2015-10-01 | This submission is the final filing | No |
| 2015-10-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2015-10-01 | Plan is a collectively bargained plan | No |
| 2015-10-01 | Plan funding arrangement – Insurance | Yes |
| 2015-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2015-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2015-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2014: NEWCOMB OIL CO., LLC EMPLOYEE BENEFIT PLAN 2014 form 5500 responses |
|---|
| 2014-10-01 | Type of plan entity | Single employer plan |
| 2014-10-01 | Submission has been amended | No |
| 2014-10-01 | This submission is the final filing | No |
| 2014-10-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2014-10-01 | Plan is a collectively bargained plan | No |
| 2014-10-01 | Plan funding arrangement – Insurance | Yes |
| 2014-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2014-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2014-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2013: NEWCOMB OIL CO., LLC EMPLOYEE BENEFIT PLAN 2013 form 5500 responses |
|---|
| 2013-10-01 | Type of plan entity | Single employer plan |
| 2013-10-01 | Submission has been amended | No |
| 2013-10-01 | This submission is the final filing | No |
| 2013-10-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2013-10-01 | Plan is a collectively bargained plan | No |
| 2013-10-01 | Plan funding arrangement – Insurance | Yes |
| 2013-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2013-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2013-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2012: NEWCOMB OIL CO., LLC EMPLOYEE BENEFIT PLAN 2012 form 5500 responses |
|---|
| 2012-10-01 | Type of plan entity | Single employer plan |
| 2012-10-01 | Submission has been amended | No |
| 2012-10-01 | This submission is the final filing | No |
| 2012-10-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2012-10-01 | Plan is a collectively bargained plan | No |
| 2012-10-01 | Plan funding arrangement – Insurance | Yes |
| 2012-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2012-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2012-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2011: NEWCOMB OIL CO., LLC EMPLOYEE BENEFIT PLAN 2011 form 5500 responses |
|---|
| 2011-10-01 | Type of plan entity | Single employer plan |
| 2011-10-01 | Submission has been amended | No |
| 2011-10-01 | This submission is the final filing | No |
| 2011-10-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2011-10-01 | Plan is a collectively bargained plan | No |
| 2011-10-01 | Plan funding arrangement – Insurance | Yes |
| 2011-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2011-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2011-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2010: NEWCOMB OIL CO., LLC EMPLOYEE BENEFIT PLAN 2010 form 5500 responses |
|---|
| 2010-10-01 | Type of plan entity | Single employer plan |
| 2010-10-01 | Submission has been amended | No |
| 2010-10-01 | This submission is the final filing | No |
| 2010-10-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2010-10-01 | Plan is a collectively bargained plan | No |
| 2010-10-01 | Plan funding arrangement – Insurance | Yes |
| 2010-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2010-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2010-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2009: NEWCOMB OIL CO., LLC EMPLOYEE BENEFIT PLAN 2009 form 5500 responses |
|---|
| 2009-10-01 | Type of plan entity | Single employer plan |
| 2009-10-01 | Submission has been amended | No |
| 2009-10-01 | This submission is the final filing | No |
| 2009-10-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2009-10-01 | Plan is a collectively bargained plan | No |
| 2009-10-01 | Plan funding arrangement – Insurance | Yes |
| 2009-10-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2009-10-01 | Plan benefit arrangement – Insurance | Yes |
| 2009-10-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| ANTHEM HEALTH PLAN OF KENTUCKY D.B.A. ANTHEM BLUECROSS BLUESHIELD (National Association of Insurance Commissioners NAIC id number: 95120 ) |
| Policy contract number | W26601 |
| Policy instance | 8 |
| Insurance contract or identification number | W26601 | | Number of Individuals Covered | 845 | | Insurance policy start date | 2022-10-01 | | Insurance policy end date | 2023-09-30 | | Total amount of commissions paid to insurance broker | USD $5,396 | | Total amount of fees paid to insurance company | USD $1,413 | | Health Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Other welfare benefits provided | HEALTH INDEMNITY | | Welfare Benefit Premiums Paid to Carrier | USD $97,449 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,396 | | Amount paid for insurance broker fees | 1413 | | Additional information about fees paid to insurance broker | BONUS PAID | | Insurance broker organization code? | 3 |
|
| ANTHEM HEALTH PLAN OF KENTUCKY D.B.A. ANTHEM BLUECROSS BLUESHIELD (National Association of Insurance Commissioners NAIC id number: 95120 ) |
| Policy contract number | W26601-EAP |
| Policy instance | 1 |
| Insurance contract or identification number | W26601-EAP | | Number of Individuals Covered | 1349 | | Insurance policy start date | 2022-10-01 | | Insurance policy end date | 2023-09-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | EMPLOYEE ASSISTANCE PROGRAM | | Welfare Benefit Premiums Paid to Carrier | USD $7,185 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUC 083V5 |
| Policy instance | 2 |
| Insurance contract or identification number | GUC 083V5 | | Number of Individuals Covered | 301 | | Insurance policy start date | 2022-10-01 | | Insurance policy end date | 2023-09-30 | | Total amount of commissions paid to insurance broker | USD $13,221 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | VOLUNTARY SHORT-TERM DISABILITY | | Welfare Benefit Premiums Paid to Carrier | USD $88,141 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $13,221 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLTD 083V5 |
| Policy instance | 3 |
| Insurance contract or identification number | GLTD 083V5 | | Number of Individuals Covered | 169 | | Insurance policy start date | 2022-10-01 | | Insurance policy end date | 2023-09-30 | | Total amount of commissions paid to insurance broker | USD $4,914 | | Total amount of fees paid to insurance company | USD $1,638 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $32,762 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,914 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 1638 | | Additional information about fees paid to insurance broker | ADMINISTRATION FEE |
|
| SYMETRA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68608 ) |
| Policy contract number | 16-014915-000 |
| Policy instance | 4 |
| Insurance contract or identification number | 16-014915-000 | | Number of Individuals Covered | 1018 | | Insurance policy start date | 2022-10-01 | | Insurance policy end date | 2023-09-30 | | Total amount of commissions paid to insurance broker | USD $71,332 | | Total amount of fees paid to insurance company | USD $14,298 | | Health Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $71,332 | | Amount paid for insurance broker fees | 14298 | | Additional information about fees paid to insurance broker | GROUP VOLUME BONUS | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL OF KENTUCKY (National Association of Insurance Commissioners NAIC id number: 54674 ) |
| Policy contract number | 0670240 |
| Policy instance | 5 |
| Insurance contract or identification number | 0670240 | | Number of Individuals Covered | 775 | | Insurance policy start date | 2022-10-01 | | Insurance policy end date | 2023-09-30 | | Total amount of commissions paid to insurance broker | USD $23,383 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Other welfare benefits provided | VOLUNTARY OPTIONAL DENTAL | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $18,811 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG 083V5 |
| Policy instance | 6 |
| Insurance contract or identification number | GLUG 083V5 | | Number of Individuals Covered | 169 | | Insurance policy start date | 2022-10-01 | | Insurance policy end date | 2023-09-30 | | Total amount of commissions paid to insurance broker | USD $1,070 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $7,131 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,070 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GVTL 083V5 |
| Policy instance | 7 |
| Insurance contract or identification number | GVTL 083V5 | | Number of Individuals Covered | 260 | | Insurance policy start date | 2022-10-01 | | Insurance policy end date | 2023-09-30 | | Total amount of commissions paid to insurance broker | USD $18,537 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | VOLUNTARY TERM LIFE | | Welfare Benefit Premiums Paid to Carrier | USD $123,581 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $18,537 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG 083V5 |
| Policy instance | 1 |
| Insurance contract or identification number | GLUG 083V5 | | Number of Individuals Covered | 162 | | Insurance policy start date | 2021-10-01 | | Insurance policy end date | 2022-09-30 | | Total amount of commissions paid to insurance broker | USD $1,027 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $6,844 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,027 | | Insurance broker organization code? | 3 |
|
| SYMETRA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68608 ) |
| Policy contract number | 910742147 |
| Policy instance | 2 |
| Insurance contract or identification number | 910742147 | | Number of Individuals Covered | 499 | | Insurance policy start date | 2021-10-01 | | Insurance policy end date | 2022-09-30 | | Total amount of commissions paid to insurance broker | USD $60,113 | | Total amount of fees paid to insurance company | USD $8,507 | | Health Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $60,113 | | Amount paid for insurance broker fees | 8507 | | Additional information about fees paid to insurance broker | GROUP VOLUME BONUS | | Insurance broker organization code? | 3 |
|
| ANTHEM HEALTH PLAN OF KENTUCKY D.B.A. ANTHEM BLUECROSS BLUESHIELD (National Association of Insurance Commissioners NAIC id number: 95120 ) |
| Policy contract number | W26601-EAP |
| Policy instance | 3 |
| Insurance contract or identification number | W26601-EAP | | Number of Individuals Covered | 1724 | | Insurance policy start date | 2021-10-01 | | Insurance policy end date | 2022-09-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | EMPLOYEE ASSISTANCE PROGRAM | | Welfare Benefit Premiums Paid to Carrier | USD $5,999 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUC 083V5 |
| Policy instance | 4 |
| Insurance contract or identification number | GUC 083V5 | | Number of Individuals Covered | 277 | | Insurance policy start date | 2021-10-01 | | Insurance policy end date | 2022-09-30 | | Total amount of commissions paid to insurance broker | USD $11,814 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | VOLUNTARY SHORT-TERM DISABILITY | | Welfare Benefit Premiums Paid to Carrier | USD $78,762 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $11,814 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLTD 083V5 |
| Policy instance | 5 |
| Insurance contract or identification number | GLTD 083V5 | | Number of Individuals Covered | 162 | | Insurance policy start date | 2021-10-01 | | Insurance policy end date | 2022-09-30 | | Total amount of commissions paid to insurance broker | USD $4,486 | | Total amount of fees paid to insurance company | USD $2,635 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $29,905 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,486 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 2635 | | Additional information about fees paid to insurance broker | ADMINISTRATION |
|
| ANTHEM HEALTH PLAN OF KENTUCKY D.B.A. ANTHEM BLUECROSS BLUESHIELD (National Association of Insurance Commissioners NAIC id number: 95120 ) |
| Policy contract number | W26601 |
| Policy instance | 6 |
| Insurance contract or identification number | W26601 | | Number of Individuals Covered | 722 | | Insurance policy start date | 2021-10-01 | | Insurance policy end date | 2022-09-30 | | Total amount of commissions paid to insurance broker | USD $5,304 | | Total amount of fees paid to insurance company | USD $388 | | Health Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $52,455 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,304 | | Amount paid for insurance broker fees | 388 | | Additional information about fees paid to insurance broker | BONUS PAID | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL OF KENTUCKY (National Association of Insurance Commissioners NAIC id number: 54674 ) |
| Policy contract number | 0670240 |
| Policy instance | 7 |
| Insurance contract or identification number | 0670240 | | Number of Individuals Covered | 754 | | Insurance policy start date | 2021-10-01 | | Insurance policy end date | 2022-09-30 | | Total amount of commissions paid to insurance broker | USD $22,066 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Other welfare benefits provided | VOLUNTARY OPTIONAL DENTAL | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $17,595 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GVTL 083V5 |
| Policy instance | 8 |
| Insurance contract or identification number | GVTL 083V5 | | Number of Individuals Covered | 248 | | Insurance policy start date | 2021-10-01 | | Insurance policy end date | 2022-09-30 | | Total amount of commissions paid to insurance broker | USD $16,266 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | VOLUNTARY TERM LIFE | | Welfare Benefit Premiums Paid to Carrier | USD $108,443 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $16,266 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG 083V5 |
| Policy instance | 8 |
| Insurance contract or identification number | GLUG 083V5 | | Number of Individuals Covered | 154 | | Insurance policy start date | 2020-10-01 | | Insurance policy end date | 2021-09-30 | | Total amount of commissions paid to insurance broker | USD $976 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $6,505 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $976 | | Insurance broker organization code? | 3 |
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| DELTA DENTAL OF KENTUCKY (National Association of Insurance Commissioners NAIC id number: 54674 ) |
| Policy contract number | 0670240 |
| Policy instance | 7 |
| Insurance contract or identification number | 0670240 | | Number of Individuals Covered | 732 | | Insurance policy start date | 2020-10-01 | | Insurance policy end date | 2021-09-30 | | Total amount of commissions paid to insurance broker | USD $18,455 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $14,312 | | Insurance broker organization code? | 3 |
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| SYMETRA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68608 ) |
| Policy contract number | 910742147 |
| Policy instance | 6 |
| Insurance contract or identification number | 910742147 | | Number of Individuals Covered | 512 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-09-30 | | Total amount of commissions paid to insurance broker | USD $58,983 | | Total amount of fees paid to insurance company | USD $4,211 | | Health Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $58,983 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 4211 | | Additional information about fees paid to insurance broker | FEES PAID |
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| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUC 083V5 |
| Policy instance | 5 |
| Insurance contract or identification number | GUC 083V5 | | Number of Individuals Covered | 280 | | Insurance policy start date | 2020-10-01 | | Insurance policy end date | 2021-09-30 | | Total amount of commissions paid to insurance broker | USD $10,289 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | VOLUNTARY SHORT-TERM DISABILITY | | Welfare Benefit Premiums Paid to Carrier | USD $68,596 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $10,289 | | Insurance broker organization code? | 3 |
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| ANTHEM HEALTH PLAN OF KENTUCKY D.B.A. ANTHEM BLUECROSS BLUESHIELD (National Association of Insurance Commissioners NAIC id number: 95120 ) |
| Policy contract number | W26601 |
| Policy instance | 4 |
| Insurance contract or identification number | W26601 | | Number of Individuals Covered | 704 | | Insurance policy start date | 2020-10-01 | | Insurance policy end date | 2021-09-30 | | Total amount of commissions paid to insurance broker | USD $5,438 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $51,703 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,438 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GVTL 083V5 |
| Policy instance | 3 |
| Insurance contract or identification number | GVTL 083V5 | | Number of Individuals Covered | 251 | | Insurance policy start date | 2020-10-01 | | Insurance policy end date | 2021-09-30 | | Total amount of commissions paid to insurance broker | USD $15,279 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | VOLUNTARY TERM LIFE | | Welfare Benefit Premiums Paid to Carrier | USD $101,857 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $15,279 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLTD 083V5 |
| Policy instance | 2 |
| Insurance contract or identification number | GLTD 083V5 | | Number of Individuals Covered | 154 | | Insurance policy start date | 2020-10-01 | | Insurance policy end date | 2021-09-30 | | Total amount of commissions paid to insurance broker | USD $3,792 | | Total amount of fees paid to insurance company | USD $1,264 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $25,283 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,792 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 1264 | | Additional information about fees paid to insurance broker | ADMINISTRATION FEES |
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| ANTHEM HEALTH PLAN OF KENTUCKY D.B.A. ANTHEM BLUECROSS BLUESHIELD (National Association of Insurance Commissioners NAIC id number: 95120 ) |
| Policy contract number | W26601-EAP |
| Policy instance | 1 |
| Insurance contract or identification number | W26601-EAP | | Number of Individuals Covered | 1349 | | Insurance policy start date | 2020-10-01 | | Insurance policy end date | 2021-09-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | EMPLOYEE ASSISTANCE PROGRAM | | Welfare Benefit Premiums Paid to Carrier | USD $6,151 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLTD 083V5 |
| Policy instance | 1 |
| Insurance contract or identification number | GLTD 083V5 | | Number of Individuals Covered | 140 | | Insurance policy start date | 2019-10-01 | | Insurance policy end date | 2020-09-30 | | Total amount of commissions paid to insurance broker | USD $3,492 | | Total amount of fees paid to insurance company | USD $885 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $23,280 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,492 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 885 | | Additional information about fees paid to insurance broker | ADMINISTRATION FEE |
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| SYMETRA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68608 ) |
| Policy contract number | 910742147 |
| Policy instance | 2 |
| Insurance contract or identification number | 910742147 | | Number of Individuals Covered | 539 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-09-30 | | Total amount of commissions paid to insurance broker | USD $56,598 | | Total amount of fees paid to insurance company | USD $5,769 | | Health Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $56,598 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 5769 | | Additional information about fees paid to insurance broker | GROUP VOLUME BONUS |
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| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG 083V5 |
| Policy instance | 3 |
| Insurance contract or identification number | GLUG 083V5 | | Number of Individuals Covered | 140 | | Insurance policy start date | 2019-10-01 | | Insurance policy end date | 2020-09-30 | | Total amount of commissions paid to insurance broker | USD $881 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $5,871 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $881 | | Insurance broker organization code? | 3 |
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| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUC 083V5 |
| Policy instance | 4 |
| Insurance contract or identification number | GUC 083V5 | | Number of Individuals Covered | 253 | | Insurance policy start date | 2019-10-01 | | Insurance policy end date | 2020-09-30 | | Total amount of commissions paid to insurance broker | USD $8,131 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | VOLUNTARY SHORT-TERM DISABILITY | | Welfare Benefit Premiums Paid to Carrier | USD $54,208 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,131 | | Insurance broker organization code? | 3 |
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| DELTA DENTAL OF KENTUCKY (National Association of Insurance Commissioners NAIC id number: 54674 ) |
| Policy contract number | 0670240 |
| Policy instance | 6 |
| Insurance contract or identification number | 0670240 | | Number of Individuals Covered | 745 | | Insurance policy start date | 2019-10-01 | | Insurance policy end date | 2020-09-30 | | Total amount of commissions paid to insurance broker | USD $16,024 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $13,784 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GVTL 083V5 |
| Policy instance | 5 |
| Insurance contract or identification number | GVTL 083V5 | | Number of Individuals Covered | 247 | | Insurance policy start date | 2019-10-01 | | Insurance policy end date | 2020-09-30 | | Total amount of commissions paid to insurance broker | USD $12,589 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | VOLUNTARY LIFE | | Welfare Benefit Premiums Paid to Carrier | USD $83,928 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $12,589 | | Insurance broker organization code? | 3 |
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| ANTHEM HEALTH PLAN OF KENTUCKY D.B.A. ANTHEM BLUECROSS BLUESHIELD (National Association of Insurance Commissioners NAIC id number: 95120 ) |
| Policy contract number | W26601 |
| Policy instance | 7 |
| Insurance contract or identification number | W26601 | | Number of Individuals Covered | 702 | | Insurance policy start date | 2019-10-01 | | Insurance policy end date | 2020-09-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $46,701 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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| ANTHEM HEALTH PLAN OF KENTUCKY D.B.A. ANTHEM BLUECROSS BLUESHIELD (National Association of Insurance Commissioners NAIC id number: 95120 ) |
| Policy contract number | W26601 |
| Policy instance | 2 |
| Insurance contract or identification number | W26601 | | Number of Individuals Covered | 392 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-09-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $19,446 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLTD 083V5 |
| Policy instance | 3 |
| Insurance contract or identification number | GLTD 083V5 | | Number of Individuals Covered | 137 | | Insurance policy start date | 2018-10-01 | | Insurance policy end date | 2019-09-30 | | Total amount of commissions paid to insurance broker | USD $3,240 | | Total amount of fees paid to insurance company | USD $0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $21,598 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,240 | | Insurance broker organization code? | 3 |
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| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG 083V5 |
| Policy instance | 4 |
| Insurance contract or identification number | GLUG 083V5 | | Number of Individuals Covered | 137 | | Insurance policy start date | 2018-10-01 | | Insurance policy end date | 2019-09-30 | | Total amount of commissions paid to insurance broker | USD $682 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $4,546 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $682 | | Insurance broker organization code? | 3 |
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| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUC 083V5 |
| Policy instance | 5 |
| Insurance contract or identification number | GUC 083V5 | | Number of Individuals Covered | 110 | | Insurance policy start date | 2018-10-01 | | Insurance policy end date | 2019-09-30 | | Total amount of commissions paid to insurance broker | USD $3,679 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | VOLUNTARY SHORT-TERM DISABILITY | | Welfare Benefit Premiums Paid to Carrier | USD $24,524 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,679 | | Insurance broker organization code? | 3 |
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| DELTA DENTAL OF KENTUCKY (National Association of Insurance Commissioners NAIC id number: 54674 ) |
| Policy contract number | 0670240 |
| Policy instance | 6 |
| Insurance contract or identification number | 0670240 | | Number of Individuals Covered | 634 | | Insurance policy start date | 2018-10-01 | | Insurance policy end date | 2019-09-30 | | Total amount of commissions paid to insurance broker | USD $13,836 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $13,836 | | Insurance broker organization code? | 3 |
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| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GVTL 083V5 |
| Policy instance | 1 |
| Insurance contract or identification number | GVTL 083V5 | | Number of Individuals Covered | 81 | | Insurance policy start date | 2018-10-01 | | Insurance policy end date | 2019-09-30 | | Total amount of commissions paid to insurance broker | USD $7,057 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | VOLUNTARY LIFE | | Welfare Benefit Premiums Paid to Carrier | USD $47,045 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,057 | | Insurance broker organization code? | 3 |
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| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUC 083V5 |
| Policy instance | 1 |
| Insurance contract or identification number | GUC 083V5 | | Number of Individuals Covered | 103 | | Insurance policy start date | 2017-10-01 | | Insurance policy end date | 2018-09-30 | | Total amount of commissions paid to insurance broker | USD $3,341 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | VOLUNTARY SHORT-TERM DISABILITY | | Welfare Benefit Premiums Paid to Carrier | USD $22,276 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GVTL 083V5 |
| Policy instance | 2 |
| Insurance contract or identification number | GVTL 083V5 | | Number of Individuals Covered | 71 | | Insurance policy start date | 2017-10-01 | | Insurance policy end date | 2018-09-30 | | Total amount of commissions paid to insurance broker | USD $6,262 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | VOLUNTARY LIFE | | Welfare Benefit Premiums Paid to Carrier | USD $41,748 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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| DELTA DENTAL OF KENTUCKY (National Association of Insurance Commissioners NAIC id number: 54674 ) |
| Policy contract number | 0670240 |
| Policy instance | 3 |
| Insurance contract or identification number | 0670240 | | Number of Individuals Covered | 563 | | Insurance policy start date | 2017-10-01 | | Insurance policy end date | 2018-09-30 | | Total amount of commissions paid to insurance broker | USD $9,715 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLTD 083V5 |
| Policy instance | 4 |
| Insurance contract or identification number | GLTD 083V5 | | Number of Individuals Covered | 126 | | Insurance policy start date | 2017-10-01 | | Insurance policy end date | 2018-09-30 | | Total amount of commissions paid to insurance broker | USD $2,953 | | Total amount of fees paid to insurance company | USD $0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $19,688 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG 083V5 |
| Policy instance | 5 |
| Insurance contract or identification number | GLUG 083V5 | | Number of Individuals Covered | 126 | | Insurance policy start date | 2017-10-01 | | Insurance policy end date | 2018-09-30 | | Total amount of commissions paid to insurance broker | USD $629 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $4,197 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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