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RAFFERTY'S INC. EMPLOYEE BENEFIT PLAN 401k Plan overview

Plan NameRAFFERTY'S INC. EMPLOYEE BENEFIT PLAN
Plan identification number 502

RAFFERTY'S INC. EMPLOYEE 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

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

Company Name:RAFFERTYS, INC.
Employer identification number (EIN):610985188
NAIC Classification:722511
NAIC Description:Full-Service Restaurants

Form 5500 Filing Information

Submission information for form 5500 for 401k plan RAFFERTY'S INC. EMPLOYEE BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5022022-01-01
5022021-01-01
5022020-01-01
5022019-01-01
5022018-01-01DOUGLAS TAULBEE DOUGLAS TAULBEE2019-07-11
5022017-01-01DOUGLAS TAULBEE DOUGLAS TAULBEE2018-07-25
5022016-01-01DOUGLAS TAULBEE DOUGLAS TAULBEE2017-07-28
5022015-01-01DOUGLAS TAULBEE DOUGLAS TAULBEE2016-07-28
5022014-01-01DOUGLAS TAULBEE DOUGLAS TAULBEE2015-07-30
5022013-01-01DOUGLAS TAULBEE DOUGLAS TAULBEE2014-07-25
5022012-01-01DOUGLAS TAULBEE DOUGLAS TAULBEE2013-07-31
5022011-01-01DOUGLAS TAULBEE DOUGLAS TAULBEE2013-10-07
5022010-01-01DOUGLAS TAULBEE DOUGLAS TAULBEE2013-10-07
5022009-01-01DOUGLAS TAULBEE DOUGLAS TAULBEE2013-10-07
5022008-01-01DOUGLAS TAULBEE DOUGLAS TAULBEE2013-10-07
5022007-01-01DOUGLAS TAULBEE DOUGLAS TAULBEE2013-10-07

Plan Statistics for RAFFERTY'S INC. EMPLOYEE BENEFIT PLAN

401k plan membership statisitcs for RAFFERTY'S INC. EMPLOYEE BENEFIT PLAN

Measure Date Value
2022: RAFFERTY'S INC. EMPLOYEE BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year2022-01-01249
Total number of active participants reported on line 7a of the Form 55002022-01-01253
Number of retired or separated participants receiving benefits2022-01-010
Number of other retired or separated participants entitled to future benefits2022-01-010
Total of all active and inactive participants2022-01-01253
Number of employers contributing to the scheme2022-01-010
2021: RAFFERTY'S INC. EMPLOYEE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year2021-01-01271
Total number of active participants reported on line 7a of the Form 55002021-01-01224
Number of retired or separated participants receiving benefits2021-01-013
Number of other retired or separated participants entitled to future benefits2021-01-010
Total of all active and inactive participants2021-01-01227
2020: RAFFERTY'S INC. EMPLOYEE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year2020-01-01269
Total number of active participants reported on line 7a of the Form 55002020-01-01271
Number of retired or separated participants receiving benefits2020-01-010
Number of other retired or separated participants entitled to future benefits2020-01-010
Total of all active and inactive participants2020-01-01271
2019: RAFFERTY'S INC. EMPLOYEE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year2019-01-01285
Total number of active participants reported on line 7a of the Form 55002019-01-01252
Number of retired or separated participants receiving benefits2019-01-011
Total of all active and inactive participants2019-01-01253
2018: RAFFERTY'S INC. EMPLOYEE BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year2018-01-01296
Total number of active participants reported on line 7a of the Form 55002018-01-01271
Number of retired or separated participants receiving benefits2018-01-012
Number of other retired or separated participants entitled to future benefits2018-01-010
Total of all active and inactive participants2018-01-01273
2017: RAFFERTY'S INC. EMPLOYEE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year2017-01-01293
Total number of active participants reported on line 7a of the Form 55002017-01-01268
Total of all active and inactive participants2017-01-01268
2016: RAFFERTY'S INC. EMPLOYEE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year2016-01-01277
Total number of active participants reported on line 7a of the Form 55002016-01-01266
Total of all active and inactive participants2016-01-01266
2015: RAFFERTY'S INC. EMPLOYEE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year2015-01-01256
Total number of active participants reported on line 7a of the Form 55002015-01-01275
Total of all active and inactive participants2015-01-01275
2014: RAFFERTY'S INC. EMPLOYEE BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year2014-01-01195
Total number of active participants reported on line 7a of the Form 55002014-01-01225
Number of retired or separated participants receiving benefits2014-01-012
Total of all active and inactive participants2014-01-01227
2013: RAFFERTY'S INC. EMPLOYEE BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year2013-01-01204
Total number of active participants reported on line 7a of the Form 55002013-01-01201
Number of retired or separated participants receiving benefits2013-01-012
Total of all active and inactive participants2013-01-01203
2012: RAFFERTY'S INC. EMPLOYEE BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year2012-01-01223
Total number of active participants reported on line 7a of the Form 55002012-01-01198
Total of all active and inactive participants2012-01-01198
2011: RAFFERTY'S INC. EMPLOYEE BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year2011-01-01269
Total number of active participants reported on line 7a of the Form 55002011-01-01238
Number of retired or separated participants receiving benefits2011-01-013
Total of all active and inactive participants2011-01-01241
2010: RAFFERTY'S INC. EMPLOYEE BENEFIT PLAN 2010 401k membership
Total participants, beginning-of-year2010-01-01273
Total number of active participants reported on line 7a of the Form 55002010-01-01262
Number of retired or separated participants receiving benefits2010-01-011
Total of all active and inactive participants2010-01-01263
2009: RAFFERTY'S INC. EMPLOYEE BENEFIT PLAN 2009 401k membership
Total participants, beginning-of-year2009-01-01312
Total number of active participants reported on line 7a of the Form 55002009-01-01271
Number of retired or separated participants receiving benefits2009-01-011
Total of all active and inactive participants2009-01-01272
Total participants2009-01-010
2008: RAFFERTY'S INC. EMPLOYEE BENEFIT PLAN 2008 401k membership
Total participants, beginning-of-year2008-01-01308
Total number of active participants reported on line 7a of the Form 55002008-01-01315
Number of retired or separated participants receiving benefits2008-01-011
Total of all active and inactive participants2008-01-01316
2007: RAFFERTY'S INC. EMPLOYEE BENEFIT PLAN 2007 401k membership
Total participants, beginning-of-year2007-01-01300
Total number of active participants reported on line 7a of the Form 55002007-01-01305
Number of retired or separated participants receiving benefits2007-01-013
Total of all active and inactive participants2007-01-01308

Form 5500 Responses for RAFFERTY'S INC. EMPLOYEE BENEFIT PLAN

2022: RAFFERTY'S INC. EMPLOYEE BENEFIT PLAN 2022 form 5500 responses
2022-01-01Type of plan entityMulti-employer plan
2022-01-01Submission has been amendedNo
2022-01-01This submission is the final filingNo
2022-01-01This return/report is a short plan year return/report (less than 12 months)No
2022-01-01Plan is a collectively bargained planYes
2022-01-01Plan funding arrangement – InsuranceYes
2022-01-01Plan funding arrangement – General assets of the sponsorYes
2022-01-01Plan benefit arrangement – InsuranceYes
2022-01-01Plan benefit arrangement – General assets of the sponsorYes
2021: RAFFERTY'S INC. EMPLOYEE BENEFIT PLAN 2021 form 5500 responses
2021-01-01Type of plan entitySingle employer plan
2021-01-01Submission has been amendedNo
2021-01-01This submission is the final filingNo
2021-01-01This return/report is a short plan year return/report (less than 12 months)No
2021-01-01Plan is a collectively bargained planNo
2021-01-01Plan funding arrangement – InsuranceYes
2021-01-01Plan funding arrangement – General assets of the sponsorYes
2021-01-01Plan benefit arrangement – InsuranceYes
2021-01-01Plan benefit arrangement – General assets of the sponsorYes
2020: RAFFERTY'S INC. EMPLOYEE BENEFIT PLAN 2020 form 5500 responses
2020-01-01Type of plan entitySingle employer plan
2020-01-01Submission has been amendedNo
2020-01-01This submission is the final filingNo
2020-01-01This return/report is a short plan year return/report (less than 12 months)No
2020-01-01Plan is a collectively bargained planNo
2020-01-01Plan funding arrangement – InsuranceYes
2020-01-01Plan funding arrangement – General assets of the sponsorYes
2020-01-01Plan benefit arrangement – InsuranceYes
2020-01-01Plan benefit arrangement – General assets of the sponsorYes
2019: RAFFERTY'S INC. EMPLOYEE BENEFIT PLAN 2019 form 5500 responses
2019-01-01Type of plan entitySingle employer plan
2019-01-01Submission has been amendedNo
2019-01-01This submission is the final filingNo
2019-01-01This return/report is a short plan year return/report (less than 12 months)No
2019-01-01Plan is a collectively bargained planNo
2019-01-01Plan funding arrangement – InsuranceYes
2019-01-01Plan funding arrangement – General assets of the sponsorYes
2019-01-01Plan benefit arrangement – InsuranceYes
2019-01-01Plan benefit arrangement – General assets of the sponsorYes
2018: RAFFERTY'S INC. EMPLOYEE BENEFIT PLAN 2018 form 5500 responses
2018-01-01Type of plan entitySingle employer plan
2018-01-01Submission has been amendedNo
2018-01-01This submission is the final filingNo
2018-01-01This return/report is a short plan year return/report (less than 12 months)No
2018-01-01Plan is a collectively bargained planNo
2018-01-01Plan funding arrangement – InsuranceYes
2018-01-01Plan funding arrangement – General assets of the sponsorYes
2018-01-01Plan benefit arrangement – InsuranceYes
2018-01-01Plan benefit arrangement – General assets of the sponsorYes
2017: RAFFERTY'S INC. EMPLOYEE BENEFIT PLAN 2017 form 5500 responses
2017-01-01Type of plan entitySingle employer plan
2017-01-01Submission has been amendedNo
2017-01-01This submission is the final filingNo
2017-01-01This return/report is a short plan year return/report (less than 12 months)No
2017-01-01Plan is a collectively bargained planNo
2017-01-01Plan funding arrangement – InsuranceYes
2017-01-01Plan funding arrangement – General assets of the sponsorYes
2017-01-01Plan benefit arrangement – InsuranceYes
2017-01-01Plan benefit arrangement – General assets of the sponsorYes
2016: RAFFERTY'S INC. EMPLOYEE BENEFIT PLAN 2016 form 5500 responses
2016-01-01Type of plan entitySingle employer plan
2016-01-01Submission has been amendedNo
2016-01-01This submission is the final filingNo
2016-01-01This return/report is a short plan year return/report (less than 12 months)No
2016-01-01Plan is a collectively bargained planNo
2016-01-01Plan funding arrangement – InsuranceYes
2016-01-01Plan funding arrangement – General assets of the sponsorYes
2016-01-01Plan benefit arrangement – InsuranceYes
2016-01-01Plan benefit arrangement – General assets of the sponsorYes
2015: RAFFERTY'S INC. EMPLOYEE BENEFIT PLAN 2015 form 5500 responses
2015-01-01Type of plan entitySingle employer plan
2015-01-01Submission has been amendedNo
2015-01-01This submission is the final filingNo
2015-01-01This return/report is a short plan year return/report (less than 12 months)No
2015-01-01Plan is a collectively bargained planNo
2015-01-01Plan funding arrangement – InsuranceYes
2015-01-01Plan funding arrangement – General assets of the sponsorYes
2015-01-01Plan benefit arrangement – InsuranceYes
2015-01-01Plan benefit arrangement – General assets of the sponsorYes
2014: RAFFERTY'S INC. EMPLOYEE BENEFIT PLAN 2014 form 5500 responses
2014-01-01Type of plan entitySingle employer plan
2014-01-01Submission has been amendedNo
2014-01-01This submission is the final filingNo
2014-01-01This return/report is a short plan year return/report (less than 12 months)No
2014-01-01Plan is a collectively bargained planNo
2014-01-01Plan funding arrangement – InsuranceYes
2014-01-01Plan funding arrangement – General assets of the sponsorYes
2014-01-01Plan benefit arrangement – InsuranceYes
2014-01-01Plan benefit arrangement – General assets of the sponsorYes
2013: RAFFERTY'S INC. EMPLOYEE BENEFIT PLAN 2013 form 5500 responses
2013-01-01Type of plan entitySingle employer plan
2013-01-01Submission has been amendedNo
2013-01-01This submission is the final filingNo
2013-01-01This return/report is a short plan year return/report (less than 12 months)No
2013-01-01Plan is a collectively bargained planNo
2013-01-01Plan funding arrangement – InsuranceYes
2013-01-01Plan funding arrangement – General assets of the sponsorYes
2013-01-01Plan benefit arrangement – InsuranceYes
2013-01-01Plan benefit arrangement – General assets of the sponsorYes
2012: RAFFERTY'S INC. EMPLOYEE BENEFIT PLAN 2012 form 5500 responses
2012-01-01Type of plan entitySingle employer plan
2012-01-01Submission has been amendedNo
2012-01-01This submission is the final filingNo
2012-01-01This return/report is a short plan year return/report (less than 12 months)No
2012-01-01Plan is a collectively bargained planNo
2012-01-01Plan funding arrangement – InsuranceYes
2012-01-01Plan funding arrangement – General assets of the sponsorYes
2012-01-01Plan benefit arrangement – InsuranceYes
2012-01-01Plan benefit arrangement – General assets of the sponsorYes
2011: RAFFERTY'S INC. EMPLOYEE BENEFIT PLAN 2011 form 5500 responses
2011-01-01Type of plan entitySingle employer plan
2011-01-01Submission has been amendedNo
2011-01-01This submission is the final filingNo
2011-01-01This return/report is a short plan year return/report (less than 12 months)No
2011-01-01Plan is a collectively bargained planNo
2011-01-01Plan funding arrangement – InsuranceYes
2011-01-01Plan funding arrangement – General assets of the sponsorYes
2011-01-01Plan benefit arrangement – InsuranceYes
2011-01-01Plan benefit arrangement – General assets of the sponsorYes
2010: RAFFERTY'S INC. EMPLOYEE BENEFIT PLAN 2010 form 5500 responses
2010-01-01Type of plan entitySingle employer plan
2010-01-01Submission has been amendedNo
2010-01-01This submission is the final filingNo
2010-01-01This return/report is a short plan year return/report (less than 12 months)No
2010-01-01Plan is a collectively bargained planNo
2010-01-01Plan funding arrangement – InsuranceYes
2010-01-01Plan funding arrangement – General assets of the sponsorYes
2010-01-01Plan benefit arrangement – InsuranceYes
2010-01-01Plan benefit arrangement – General assets of the sponsorYes
2009: RAFFERTY'S INC. EMPLOYEE BENEFIT PLAN 2009 form 5500 responses
2009-01-01Type of plan entitySingle employer plan
2009-01-01Submission has been amendedNo
2009-01-01This submission is the final filingNo
2009-01-01This return/report is a short plan year return/report (less than 12 months)No
2009-01-01Plan is a collectively bargained planNo
2009-01-01Plan funding arrangement – InsuranceYes
2009-01-01Plan funding arrangement – General assets of the sponsorYes
2009-01-01Plan benefit arrangement – InsuranceYes
2009-01-01Plan benefit arrangement – General assets of the sponsorYes
2008: RAFFERTY'S INC. EMPLOYEE BENEFIT PLAN 2008 form 5500 responses
2008-01-01Type of plan entitySingle employer plan
2008-01-01Submission has been amendedNo
2008-01-01This submission is the final filingNo
2008-01-01This return/report is a short plan year return/report (less than 12 months)No
2008-01-01Plan is a collectively bargained planNo
2008-01-01Plan funding arrangement – InsuranceYes
2008-01-01Plan funding arrangement – General assets of the sponsorYes
2008-01-01Plan benefit arrangement – InsuranceYes
2008-01-01Plan benefit arrangement – General assets of the sponsorYes
2007: RAFFERTY'S INC. EMPLOYEE BENEFIT PLAN 2007 form 5500 responses
2007-01-01Type of plan entitySingle employer plan
2007-01-01First time form 5500 has been submittedYes
2007-01-01Submission has been amendedNo
2007-01-01This submission is the final filingNo
2007-01-01This return/report is a short plan year return/report (less than 12 months)No
2007-01-01Plan is a collectively bargained planNo
2007-01-01Plan funding arrangement – InsuranceYes
2007-01-01Plan funding arrangement – General assets of the sponsorYes
2007-01-01Plan benefit arrangement – InsuranceYes
2007-01-01Plan benefit arrangement – General assets of the sponsorYes

Insurance Providers Used on plan

ANTHEM HEALTH PLAN OF KENTUCKY D.B.A. ANTHEM BLUECROSS BLUESHIELD (National Association of Insurance Commissioners NAIC id number: 95120 )
Policy contract numberW26792
Policy instance 5
Insurance contract or identification numberW26792
Number of Individuals Covered285
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $2,129
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $405,702
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,129
Amount paid for insurance broker fees0
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLUG0AA5T
Policy instance 4
Insurance contract or identification numberGLUG0AA5T
Number of Individuals Covered246
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $2,781
Total amount of fees paid to insurance companyUSD $1,036
Life Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $12,639
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,781
Amount paid for insurance broker fees857
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 numberGUC 0AA5T
Policy instance 3
Insurance contract or identification numberGUC 0AA5T
Number of Individuals Covered41
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $2,408
Total amount of fees paid to insurance companyUSD $962
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $10,944
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,408
Amount paid for insurance broker fees796
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 numberGVTL0AA5T
Policy instance 2
Insurance contract or identification numberGVTL0AA5T
Number of Individuals Covered64
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $13,021
Total amount of fees paid to insurance companyUSD $4,733
Life Insurance Welfare BenefitYes
Other welfare benefits providedAD&D VOLUNTARY
Welfare Benefit Premiums Paid to CarrierUSD $59,188
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $13,021
Amount paid for insurance broker fees3917
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 numberGLTD0AA5T
Policy instance 1
Insurance contract or identification numberGLTD0AA5T
Number of Individuals Covered151
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $8,036
Total amount of fees paid to insurance companyUSD $1,918
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $36,525
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $8,036
Amount paid for insurance broker fees1587
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 numberGVTL0AA5T
Policy instance 1
Insurance contract or identification numberGVTL0AA5T
Number of Individuals Covered65
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $13,256
Total amount of fees paid to insurance companyUSD $4,096
Life Insurance Welfare BenefitYes
Other welfare benefits providedAD&D VOLUNTARY
Welfare Benefit Premiums Paid to CarrierUSD $60,255
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $13,256
Amount paid for insurance broker fees3390
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 numberGLTD0AA5T
Policy instance 2
Insurance contract or identification numberGLTD0AA5T
Number of Individuals Covered150
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $5,378
Total amount of fees paid to insurance companyUSD $1,620
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $24,445
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,378
Amount paid for insurance broker fees1341
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 numberGUC 0AA5T
Policy instance 3
Insurance contract or identification numberGUC 0AA5T
Number of Individuals Covered43
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $2,699
Total amount of fees paid to insurance companyUSD $882
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $12,270
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,699
Amount paid for insurance broker fees730
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 numberGLUG0AA5T
Policy instance 4
Insurance contract or identification numberGLUG0AA5T
Number of Individuals Covered229
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $2,889
Total amount of fees paid to insurance companyUSD $939
Life Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $13,131
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,889
Amount paid for insurance broker fees777
Additional information about fees paid to insurance brokerOTHER COMPENSATION
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 numberW26792
Policy instance 5
Insurance contract or identification numberW26792
Number of Individuals Covered261
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $49,135
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $291,053
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $49,135
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGVTL0AA5T
Policy instance 1
Insurance contract or identification numberGVTL0AA5T
Number of Individuals Covered73
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $13,537
Total amount of fees paid to insurance companyUSD $4,047
Life Insurance Welfare BenefitYes
Other welfare benefits providedAD&D VOLUNTARY
Welfare Benefit Premiums Paid to CarrierUSD $61,530
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $13,537
Amount paid for insurance broker fees3349
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 numberGLTD0AA5T
Policy instance 2
Insurance contract or identification numberGLTD0AA5T
Number of Individuals Covered161
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $5,357
Total amount of fees paid to insurance companyUSD $1,762
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $24,531
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,357
Amount paid for insurance broker fees1458
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 numberGUC 0AA5T
Policy instance 3
Insurance contract or identification numberGUC 0AA5T
Number of Individuals Covered49
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $2,898
Total amount of fees paid to insurance companyUSD $978
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $13,171
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,898
Amount paid for insurance broker fees809
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 numberGLUG0AA5T
Policy instance 4
Insurance contract or identification numberGLUG0AA5T
Number of Individuals Covered272
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $3,104
Total amount of fees paid to insurance companyUSD $1,011
Life Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $14,110
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,104
Amount paid for insurance broker fees837
Additional information about fees paid to insurance brokerOTHER COMPENSATION
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 numberW26792
Policy instance 5
Insurance contract or identification numberW26792
Number of Individuals Covered304
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $58,346
Total amount of fees paid to insurance companyUSD $1,291
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $293,274
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $58,346
Amount paid for insurance broker fees1291
Additional information about fees paid to insurance brokerFEES PAID
Insurance broker organization code?3
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGVTL0AA5T
Policy instance 1
Insurance contract or identification numberGVTL0AA5T
Number of Individuals Covered74
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $12,278
Total amount of fees paid to insurance companyUSD $2,356
Life Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedAD&D VOLUNTARY
Welfare Benefit Premiums Paid to CarrierUSD $55,809
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $12,278
Amount paid for insurance broker fees2356
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 numberGLTD0AA5T
Policy instance 2
Insurance contract or identification numberGLTD0AA5T
Number of Individuals Covered166
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $5,346
Total amount of fees paid to insurance companyUSD $1,077
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $24,301
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,346
Amount paid for insurance broker fees1077
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 numberGUC 0AA5T
Policy instance 3
Insurance contract or identification numberGUC 0AA5T
Number of Individuals Covered51
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $2,966
Total amount of fees paid to insurance companyUSD $607
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $13,482
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,966
Amount paid for insurance broker fees607
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 numberGLUG0AA5T
Policy instance 4
Insurance contract or identification numberGLUG0AA5T
Number of Individuals Covered260
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $3,070
Total amount of fees paid to insurance companyUSD $644
Life Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $13,957
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,070
Amount paid for insurance broker fees644
Additional information about fees paid to insurance brokerOTHER COMPENSATION
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 number635949
Policy instance 5
Insurance contract or identification number635949
Number of Individuals Covered141
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
ANTHEM HEALTH PLAN OF KENTUCKY D.B.A. ANTHEM BLUECROSS BLUESHIELD (National Association of Insurance Commissioners NAIC id number: 95120 )
Policy contract number00240934
Policy instance 6
Insurance contract or identification number00240934
Number of Individuals Covered290
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $54,958
Total amount of fees paid to insurance companyUSD $555
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $290,609
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $54,958
Amount paid for insurance broker fees555
Additional information about fees paid to insurance brokerFEES 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 number00240934
Policy instance 6
Insurance contract or identification number00240934
Number of Individuals Covered313
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $3,008
Total amount of fees paid to insurance companyUSD $316
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $307,775
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,664
Amount paid for insurance broker fees316
Additional information about fees paid to insurance brokerOTHER COMPENSATION
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 number635949
Policy instance 5
Insurance contract or identification number635949
Number of Individuals Covered144
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $51,774
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 numberGLUG0AA5T
Policy instance 4
Insurance contract or identification numberGLUG0AA5T
Number of Individuals Covered263
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $3,149
Total amount of fees paid to insurance companyUSD $875
Life Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $14,314
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,149
Amount paid for insurance broker fees875
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 numberGUC 0AA5T
Policy instance 3
Insurance contract or identification numberGUC 0AA5T
Number of Individuals Covered51
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $2,968
Total amount of fees paid to insurance companyUSD $896
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $13,490
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,968
Amount paid for insurance broker fees896
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 numberGLTD0AA5T
Policy instance 2
Insurance contract or identification numberGLTD0AA5T
Number of Individuals Covered167
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $5,265
Total amount of fees paid to insurance companyUSD $1,450
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $23,933
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,265
Amount paid for insurance broker fees1450
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 numberGVTL0AA5T
Policy instance 1
Insurance contract or identification numberGVTL0AA5T
Number of Individuals Covered74
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $11,518
Total amount of fees paid to insurance companyUSD $3,169
Life Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedAD&D VOLUNTARY
Welfare Benefit Premiums Paid to CarrierUSD $52,353
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $11,518
Amount paid for insurance broker fees3169
Additional information about fees paid to insurance brokerOTHER COMPENSATION
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 number00240934
Policy instance 6
Insurance contract or identification number00240934
Number of Individuals Covered346
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $3,397
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $308,761
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Amount paid for insurance broker fees3397
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
Insurance broker nameINSURANCE SPECIALISTS LLC
ANTHEM HEALTH PLAN OF KENTUCKY D.B.A. ANTHEM BLUECROSS BLUESHIELD (National Association of Insurance Commissioners NAIC id number: 95120 )
Policy contract number635949
Policy instance 5
Insurance contract or identification number635949
Number of Individuals Covered145
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $60,105
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 numberGLUG0AA5T
Policy instance 4
Insurance contract or identification numberGLUG0AA5T
Number of Individuals Covered284
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $3,210
Total amount of fees paid to insurance companyUSD $651
Life Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $14,591
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,210
Insurance broker organization code?3
Amount paid for insurance broker fees651
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker nameINSURANCE SPECIALISTS LLC
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGUC 0AA5T
Policy instance 3
Insurance contract or identification numberGUC 0AA5T
Number of Individuals Covered52
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $3,285
Total amount of fees paid to insurance companyUSD $722
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $14,933
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,285
Insurance broker organization code?3
Amount paid for insurance broker fees722
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker nameINSURANCE SPECIALISTS LLC
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLTD0AA5T
Policy instance 2
Insurance contract or identification numberGLTD0AA5T
Number of Individuals Covered168
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $5,316
Total amount of fees paid to insurance companyUSD $1,064
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $24,166
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,316
Insurance broker organization code?3
Amount paid for insurance broker fees1064
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker nameINSURANCE SPECIALISTS LLC
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGVTL0AA5T
Policy instance 1
Insurance contract or identification numberGVTL0AA5T
Number of Individuals Covered79
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $11,621
Total amount of fees paid to insurance companyUSD $2,263
Life Insurance Welfare BenefitYes
Other welfare benefits providedAD&D VOLUNTARY
Welfare Benefit Premiums Paid to CarrierUSD $52,821
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $11,621
Insurance broker organization code?3
Amount paid for insurance broker fees2263
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker nameINSURANCE SPECIALISTS LLC
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGVTL0AA5T
Policy instance 1
Insurance contract or identification numberGVTL0AA5T
Number of Individuals Covered87
Insurance policy start date2015-01-01
Insurance policy end date2015-12-31
Total amount of commissions paid to insurance brokerUSD $10,912
Total amount of fees paid to insurance companyUSD $2,619
Life Insurance Welfare BenefitYes
Other welfare benefits providedAD&D VOLUNTARY
Welfare Benefit Premiums Paid to CarrierUSD $49,602
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $10,912
Amount paid for insurance broker fees2619
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
Insurance broker nameINSURANCE SPECIALISTS LLC
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLTD0AA5T
Policy instance 2
Insurance contract or identification numberGLTD0AA5T
Number of Individuals Covered172
Insurance policy start date2015-01-01
Insurance policy end date2015-12-31
Total amount of commissions paid to insurance brokerUSD $4,788
Total amount of fees paid to insurance companyUSD $979
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $21,763
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,788
Amount paid for insurance broker fees979
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
Insurance broker nameINSURANCE SPECIALISTS LLC
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGUC 0AA5T
Policy instance 3
Insurance contract or identification numberGUC 0AA5T
Number of Individuals Covered61
Insurance policy start date2015-01-01
Insurance policy end date2015-12-31
Total amount of commissions paid to insurance brokerUSD $3,513
Total amount of fees paid to insurance companyUSD $795
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $15,970
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,513
Amount paid for insurance broker fees795
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
Insurance broker nameINSURANCE SPECIALISTS LLC
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLUG0AA5T
Policy instance 4
Insurance contract or identification numberGLUG0AA5T
Number of Individuals Covered281
Insurance policy start date2015-01-01
Insurance policy end date2015-12-31
Total amount of commissions paid to insurance brokerUSD $3,010
Total amount of fees paid to insurance companyUSD $656
Life Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $13,682
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,010
Amount paid for insurance broker fees656
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
Insurance broker nameINSURANCE SPECIALISTS LLC
ANTHEM HEALTH PLAN OF KENTUCKY D.B.A. ANTHEM BLUECROSS BLUESHIELD (National Association of Insurance Commissioners NAIC id number: 95120 )
Policy contract number635949
Policy instance 5
Insurance contract or identification number635949
Number of Individuals Covered152
Insurance policy start date2015-01-01
Insurance policy end date2015-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $56,895
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
ANTHEM HEALTH PLAN OF KENTUCKY D.B.A. ANTHEM BLUECROSS BLUESHIELD (National Association of Insurance Commissioners NAIC id number: 95120 )
Policy contract number00240934
Policy instance 6
Insurance contract or identification number00240934
Number of Individuals Covered392
Insurance policy start date2015-01-01
Insurance policy end date2015-12-31
Total amount of commissions paid to insurance brokerUSD $59,229
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $304,692
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $59,229
Insurance broker organization code?3
Insurance broker nameINSURANCE SPECIALISTS LLC
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLTD0AA5T
Policy instance 2
Insurance contract or identification numberGLTD0AA5T
Number of Individuals Covered156
Insurance policy start date2014-01-01
Insurance policy end date2014-12-31
Total amount of commissions paid to insurance brokerUSD $3,897
Total amount of fees paid to insurance companyUSD $663
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $17,714
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,897
Amount paid for insurance broker fees663
Additional information about fees paid to insurance brokerOTHER FEES
Insurance broker organization code?3
Insurance broker nameINSURANCE SPECIALISTS LLC
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGVTL0AA5T
Policy instance 1
Insurance contract or identification numberGVTL0AA5T
Number of Individuals Covered93
Insurance policy start date2014-01-01
Insurance policy end date2014-12-31
Total amount of commissions paid to insurance brokerUSD $10,478
Total amount of fees paid to insurance companyUSD $1,788
Life Insurance Welfare BenefitYes
Other welfare benefits providedAD&D VOLUNTARY
Welfare Benefit Premiums Paid to CarrierUSD $47,626
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $10,478
Amount paid for insurance broker fees1788
Additional information about fees paid to insurance brokerOTHER FEES
Insurance broker organization code?3
Insurance broker nameINSURANCE SPECIALISTS LLC
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGUC 0AA5T
Policy instance 3
Insurance contract or identification numberGUC 0AA5T
Number of Individuals Covered60
Insurance policy start date2014-01-01
Insurance policy end date2014-12-31
Total amount of commissions paid to insurance brokerUSD $3,173
Total amount of fees paid to insurance companyUSD $549
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $14,422
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,173
Amount paid for insurance broker fees549
Additional information about fees paid to insurance brokerOTHER FEES
Insurance broker organization code?3
Insurance broker nameINSURANCE SPECIALISTS LLC
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLUG0AA5T
Policy instance 4
Insurance contract or identification numberGLUG0AA5T
Number of Individuals Covered242
Insurance policy start date2014-01-01
Insurance policy end date2014-12-31
Total amount of commissions paid to insurance brokerUSD $2,607
Total amount of fees paid to insurance companyUSD $437
Life Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $11,848
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,607
Amount paid for insurance broker fees437
Additional information about fees paid to insurance brokerOTHER FEES
Insurance broker organization code?3
Insurance broker nameINSURANCE SPECIALISTS LLC
ANTHEM HEALTH PLAN OF KENTUCKY D.B.A. ANTHEM BLUECROSS BLUESHIELD (National Association of Insurance Commissioners NAIC id number: 95120 )
Policy contract number635949
Policy instance 5
Insurance contract or identification number635949
Number of Individuals Covered142
Insurance policy start date2014-01-01
Insurance policy end date2014-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $51,148
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
ANTHEM HEALTH PLAN OF KENTUCKY D.B.A. ANTHEM BLUECROSS BLUESHIELD (National Association of Insurance Commissioners NAIC id number: 95120 )
Policy contract number00240934
Policy instance 6
Insurance contract or identification number00240934
Number of Individuals Covered377
Insurance policy start date2014-01-01
Insurance policy end date2014-12-31
Total amount of commissions paid to insurance brokerUSD $44,158
Total amount of fees paid to insurance companyUSD $4,000
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $183,661
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $44,158
Amount paid for insurance broker fees4000
Additional information about fees paid to insurance brokerFEES PAID
Insurance broker organization code?3
Insurance broker nameINSURANCE SPECIALISTS LLC
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGVTL0AA5T
Policy instance 1
Insurance contract or identification numberGVTL0AA5T
Number of Individuals Covered100
Insurance policy start date2013-01-01
Insurance policy end date2013-12-31
Total amount of commissions paid to insurance brokerUSD $10,366
Total amount of fees paid to insurance companyUSD $1,618
Life Insurance Welfare BenefitYes
Other welfare benefits providedAD&D VOLUNTARY
Welfare Benefit Premiums Paid to CarrierUSD $47,116
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $10,336
Amount paid for insurance broker fees1618
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
Insurance broker nameINSURANCE SPECIALISTS LLC
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLTD0AA5T
Policy instance 2
Insurance contract or identification numberGLTD0AA5T
Number of Individuals Covered139
Insurance policy start date2013-01-01
Insurance policy end date2013-12-31
Total amount of commissions paid to insurance brokerUSD $3,859
Total amount of fees paid to insurance companyUSD $590
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $17,540
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,859
Amount paid for insurance broker fees590
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
Insurance broker nameINSURANCE SPECIALISTS LLC
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGUC 0AA5T
Policy instance 3
Insurance contract or identification numberGUC 0AA5T
Number of Individuals Covered57
Insurance policy start date2013-01-01
Insurance policy end date2013-12-31
Total amount of commissions paid to insurance brokerUSD $3,191
Total amount of fees paid to insurance companyUSD $493
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $14,506
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,191
Amount paid for insurance broker fees493
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
Insurance broker nameINSURANCE SPECIALISTS LLC
MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )
Policy contract numberGLUG0AA5T
Policy instance 4
Insurance contract or identification numberGLUG0AA5T
Number of Individuals Covered220
Insurance policy start date2013-01-01
Insurance policy end date2013-12-31
Total amount of commissions paid to insurance brokerUSD $2,545
Total amount of fees paid to insurance companyUSD $407
Life Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $11,567
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,545
Amount paid for insurance broker fees407
Additional information about fees paid to insurance brokerOTHER COMPENSATION
Insurance broker organization code?3
Insurance broker nameINSURANCE SPECIALISTS LLC
HUMANA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 73288 )
Policy contract number680492
Policy instance 5
Insurance contract or identification number680492
Number of Individuals Covered197
Insurance policy start date2013-01-01
Insurance policy end date2013-12-31
Total amount of commissions paid to insurance brokerUSD $34,608
Total amount of fees paid to insurance companyUSD $0
Welfare Benefit Premiums Paid to CarrierUSD $169,087
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $34,608
Insurance broker organization code?3
Insurance broker nameINSURANCE SPECIALISTS LLC
HUMANA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 73288 )
Policy contract number680492
Policy instance 1
Insurance contract or identification number680492
Number of Individuals Covered194
Insurance policy start date2012-01-01
Insurance policy end date2012-12-31
Total amount of commissions paid to insurance brokerUSD $35,058
Total amount of fees paid to insurance companyUSD $0
Welfare Benefit Premiums Paid to CarrierUSD $175,115
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $35,058
Insurance broker organization code?3
Insurance broker nameINSURANCE SPECIALISTS LLC
HUMANA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 73288 )
Policy contract number680492
Policy instance 1
Insurance contract or identification number680492
Number of Individuals Covered220
Insurance policy start date2011-01-01
Insurance policy end date2011-12-31
Total amount of commissions paid to insurance brokerUSD $33,021
Total amount of fees paid to insurance companyUSD $0
Welfare Benefit Premiums Paid to CarrierUSD $122,311
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
HUMANA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 73288 )
Policy contract number680492
Policy instance 1
Insurance contract or identification number680492
Number of Individuals Covered243
Insurance policy start date2010-01-01
Insurance policy end date2010-12-31
Total amount of commissions paid to insurance brokerUSD $33,240
Total amount of fees paid to insurance companyUSD $0
Welfare Benefit Premiums Paid to CarrierUSD $109,584
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
HUMANA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 73288 )
Policy contract number680492
Policy instance 1
Insurance contract or identification number680492
Number of Individuals Covered297
Insurance policy start date2008-01-01
Insurance policy end date2008-12-31
Total amount of commissions paid to insurance brokerUSD $41,317
Total amount of fees paid to insurance companyUSD $0
Welfare Benefit Premiums Paid to CarrierUSD $98,238
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $26,281
Insurance broker organization code?3
Insurance broker nameJODI BRYANT
HUMANA INSURANCE COMPANY OF KENTUCKY INC (National Association of Insurance Commissioners NAIC id number: 60219 )
Policy contract number680492
Policy instance 1
Insurance contract or identification number680492
Number of Individuals Covered283
Insurance policy start date2007-01-01
Insurance policy end date2007-12-31
Total amount of commissions paid to insurance brokerUSD $46,139
Welfare Benefit Premiums Paid to CarrierUSD $88,727
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $46,139
Insurance broker organization code?3
Insurance broker nameJODI BRYANT

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