CHARLES TOMBRAS ADVERTISING, INC. has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan CHARLES TOMBRAS ADVERTISING, INC. HEALTH INSURANCE
401k plan membership statisitcs for CHARLES TOMBRAS ADVERTISING, INC. HEALTH INSURANCE
| Measure | Date | Value |
|---|
| 2021: CHARLES TOMBRAS ADVERTISING, INC. HEALTH INSURANCE 2021 401k membership |
|---|
| Total participants, beginning-of-year | 2021-09-01 | 532 |
| Total number of active participants reported on line 7a of the Form 5500 | 2021-09-01 | 640 |
| Total of all active and inactive participants | 2021-09-01 | 640 |
| 2020: CHARLES TOMBRAS ADVERTISING, INC. HEALTH INSURANCE 2020 401k membership |
|---|
| Total participants, beginning-of-year | 2020-09-01 | 300 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-09-01 | 532 |
| Total of all active and inactive participants | 2020-09-01 | 532 |
| 2019: CHARLES TOMBRAS ADVERTISING, INC. HEALTH INSURANCE 2019 401k membership |
|---|
| Total participants, beginning-of-year | 2019-09-01 | 305 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-09-01 | 300 |
| Total of all active and inactive participants | 2019-09-01 | 300 |
| 2018: CHARLES TOMBRAS ADVERTISING, INC. HEALTH INSURANCE 2018 401k membership |
|---|
| Total participants, beginning-of-year | 2018-09-01 | 259 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-09-01 | 305 |
| Number of retired or separated participants receiving benefits | 2018-09-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2018-09-01 | 0 |
| Total of all active and inactive participants | 2018-09-01 | 305 |
| 2017: CHARLES TOMBRAS ADVERTISING, INC. HEALTH INSURANCE 2017 401k membership |
|---|
| Total participants, beginning-of-year | 2017-09-01 | 244 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-09-01 | 259 |
| Number of retired or separated participants receiving benefits | 2017-09-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2017-09-01 | 0 |
| Total of all active and inactive participants | 2017-09-01 | 259 |
| 2016: CHARLES TOMBRAS ADVERTISING, INC. HEALTH INSURANCE 2016 401k membership |
|---|
| Total participants, beginning-of-year | 2016-09-01 | 244 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-09-01 | 244 |
| Number of retired or separated participants receiving benefits | 2016-09-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2016-09-01 | 0 |
| Total of all active and inactive participants | 2016-09-01 | 244 |
| 2015: CHARLES TOMBRAS ADVERTISING, INC. HEALTH INSURANCE 2015 401k membership |
|---|
| Total participants, beginning-of-year | 2015-09-01 | 173 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-09-01 | 244 |
| Number of retired or separated participants receiving benefits | 2015-09-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2015-09-01 | 0 |
| Total of all active and inactive participants | 2015-09-01 | 244 |
| 2014: CHARLES TOMBRAS ADVERTISING, INC. HEALTH INSURANCE 2014 401k membership |
|---|
| Total participants, beginning-of-year | 2014-09-01 | 110 |
| Total number of active participants reported on line 7a of the Form 5500 | 2014-09-01 | 173 |
| Number of retired or separated participants receiving benefits | 2014-09-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2014-09-01 | 0 |
| Total of all active and inactive participants | 2014-09-01 | 173 |
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | R0789644 |
| Policy instance | 5 |
| Insurance contract or identification number | R0789644 | | Number of Individuals Covered | 204 | | Insurance policy start date | 2021-09-01 | | Insurance policy end date | 2022-08-31 | | Total amount of commissions paid to insurance broker | USD $12,537 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | GCI EE PAY & GRP ACC VOL 11 | | Welfare Benefit Premiums Paid to Carrier | USD $57,990 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $10,966 | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 930676 |
| Policy instance | 4 |
| Insurance contract or identification number | 930676 | | Number of Individuals Covered | 513 | | Insurance policy start date | 2021-09-01 | | Insurance policy end date | 2022-08-31 | | Total amount of commissions paid to insurance broker | USD $2,797 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | GROUP LONG TERM CARE | | Welfare Benefit Premiums Paid to Carrier | USD $18,649 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,797 | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 427034 |
| Policy instance | 3 |
| Insurance contract or identification number | 427034 | | Number of Individuals Covered | 470 | | Insurance policy start date | 2021-09-01 | | Insurance policy end date | 2022-08-31 | | Total amount of commissions paid to insurance broker | USD $31,383 | | Total amount of fees paid to insurance company | USD $1,569 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $209,222 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $31,383 | | Amount paid for insurance broker fees | 1569 | | Additional information about fees paid to insurance broker | ADMINISTRATIVE FEES | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 427035 |
| Policy instance | 2 |
| Insurance contract or identification number | 427035 | | Number of Individuals Covered | 167 | | Insurance policy start date | 2021-09-01 | | Insurance policy end date | 2022-08-31 | | Total amount of commissions paid to insurance broker | USD $11,932 | | Total amount of fees paid to insurance company | USD $597 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $79,549 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $11,932 | | Amount paid for insurance broker fees | 597 | | Additional information about fees paid to insurance broker | ADMINISTRATIVE FEES | | Insurance broker organization code? | 3 |
|
| BLUECROSS BLUESHIELD OF TENNESSEE, INC. (National Association of Insurance Commissioners NAIC id number: 54518 ) |
| Policy contract number | 115373 |
| Policy instance | 1 |
| Insurance contract or identification number | 115373 | | Number of Individuals Covered | 640 | | Insurance policy start date | 2021-09-01 | | Insurance policy end date | 2022-08-31 | | Total amount of commissions paid to insurance broker | USD $147,969 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $36,115 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $147,969 | | Insurance broker organization code? | 3 |
|
| BLUECROSS BLUESHIELD OF TENNESSEE, INC. (National Association of Insurance Commissioners NAIC id number: 54518 ) |
| Policy contract number | 115373 |
| Policy instance | 1 |
| Insurance contract or identification number | 115373 | | Number of Individuals Covered | 532 | | Insurance policy start date | 2020-09-01 | | Insurance policy end date | 2021-08-31 | | Total amount of commissions paid to insurance broker | USD $121,457 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $29,894 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $121,457 | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 427035 |
| Policy instance | 2 |
| Insurance contract or identification number | 427035 | | Number of Individuals Covered | 140 | | Insurance policy start date | 2020-09-01 | | Insurance policy end date | 2021-08-31 | | Total amount of commissions paid to insurance broker | USD $10,296 | | Total amount of fees paid to insurance company | USD $515 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $68,637 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $10,296 | | Amount paid for insurance broker fees | 515 | | Additional information about fees paid to insurance broker | ADMINISTRATIVE FEES | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 427034 |
| Policy instance | 3 |
| Insurance contract or identification number | 427034 | | Number of Individuals Covered | 370 | | Insurance policy start date | 2020-09-01 | | Insurance policy end date | 2021-08-31 | | Total amount of commissions paid to insurance broker | USD $26,354 | | Total amount of fees paid to insurance company | USD $1,318 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $175,693 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $26,354 | | Amount paid for insurance broker fees | 1318 | | Additional information about fees paid to insurance broker | ADMINISTRATIVE FESS | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 930676 |
| Policy instance | 4 |
| Insurance contract or identification number | 930676 | | Number of Individuals Covered | 348 | | Insurance policy start date | 2020-12-01 | | Insurance policy end date | 2021-11-30 | | Total amount of commissions paid to insurance broker | USD $2,292 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | GROUP LONG TERM CARE | | Welfare Benefit Premiums Paid to Carrier | USD $16,690 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,292 | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | R0789644 |
| Policy instance | 5 |
| Insurance contract or identification number | R0789644 | | Number of Individuals Covered | 172 | | Insurance policy start date | 2020-09-01 | | Insurance policy end date | 2021-08-31 | | Total amount of commissions paid to insurance broker | USD $11,379 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | GCI EE PAY & GRP ACC VOL 11 | | Welfare Benefit Premiums Paid to Carrier | USD $52,897 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $9,954 | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | R0789644 |
| Policy instance | 5 |
| Insurance contract or identification number | R0789644 | | Number of Individuals Covered | 167 | | Insurance policy start date | 2019-09-01 | | Insurance policy end date | 2020-08-31 | | Total amount of commissions paid to insurance broker | USD $8,386 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | GCI EE PAY AND GRP ACC VOL 11 | | Welfare Benefit Premiums Paid to Carrier | USD $37,091 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,333 | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 930676 |
| Policy instance | 4 |
| Insurance contract or identification number | 930676 | | Number of Individuals Covered | 307 | | Insurance policy start date | 2019-12-01 | | Insurance policy end date | 2020-11-30 | | Total amount of commissions paid to insurance broker | USD $2,366 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | GROUP LONG TERM CARE | | Welfare Benefit Premiums Paid to Carrier | USD $15,771 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,366 | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 427034 |
| Policy instance | 3 |
| Insurance contract or identification number | 427034 | | Number of Individuals Covered | 300 | | Insurance policy start date | 2019-09-01 | | Insurance policy end date | 2020-08-31 | | Total amount of commissions paid to insurance broker | USD $23,173 | | Total amount of fees paid to insurance company | USD $1,332 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $154,483 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $23,173 | | Amount paid for insurance broker fees | 1332 | | Additional information about fees paid to insurance broker | ADMINISTRATIVE FEES | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 427035 |
| Policy instance | 2 |
| Insurance contract or identification number | 427035 | | Number of Individuals Covered | 128 | | Insurance policy start date | 2019-09-01 | | Insurance policy end date | 2020-08-31 | | Total amount of commissions paid to insurance broker | USD $9,148 | | Total amount of fees paid to insurance company | USD $532 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $60,985 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $9,148 | | Amount paid for insurance broker fees | 532 | | Additional information about fees paid to insurance broker | ADMINISTRATIVE FEES | | Insurance broker organization code? | 3 |
|
| BLUECROSS BLUESHIELD OF TENNESSEE, INC. (National Association of Insurance Commissioners NAIC id number: 54518 ) |
| Policy contract number | 115373 |
| Policy instance | 1 |
| Insurance contract or identification number | 115373 | | Number of Individuals Covered | 486 | | Insurance policy start date | 2019-09-01 | | Insurance policy end date | 2020-08-31 | | Total amount of commissions paid to insurance broker | USD $103,898 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $27,564 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $103,898 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLTD0AMCR |
| Policy instance | 8 |
| Insurance contract or identification number | GLTD0AMCR | | Number of Individuals Covered | 259 | | Insurance policy start date | 2018-09-01 | | Insurance policy end date | 2018-11-01 | | Total amount of commissions paid to insurance broker | USD $1,453 | | Total amount of fees paid to insurance company | USD $0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $9,684 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,453 | | Insurance broker organization code? | 3 |
|
| BLUECROSS BLUESHIELD OF TENNESSEE, INC. (National Association of Insurance Commissioners NAIC id number: 54518 ) |
| Policy contract number | 115373 |
| Policy instance | 1 |
| Insurance contract or identification number | 115373 | | Number of Individuals Covered | 460 | | Insurance policy start date | 2018-09-01 | | Insurance policy end date | 2019-08-31 | | Total amount of commissions paid to insurance broker | USD $98,006 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $26,044 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $98,006 | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 427035 |
| Policy instance | 2 |
| Insurance contract or identification number | 427035 | | Number of Individuals Covered | 101 | | Insurance policy start date | 2018-11-01 | | Insurance policy end date | 2019-08-31 | | Total amount of commissions paid to insurance broker | USD $6,913 | | Total amount of fees paid to insurance company | USD $895 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $44,750 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,913 | | Amount paid for insurance broker fees | 895 | | Additional information about fees paid to insurance broker | ADMINISTRATIVE FEES | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 427034 |
| Policy instance | 3 |
| Insurance contract or identification number | 427034 | | Number of Individuals Covered | 305 | | Insurance policy start date | 2018-11-01 | | Insurance policy end date | 2019-08-31 | | Total amount of commissions paid to insurance broker | USD $19,116 | | Total amount of fees paid to insurance company | USD $2,549 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $127,439 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $19,116 | | Amount paid for insurance broker fees | 2549 | | Additional information about fees paid to insurance broker | ADMINISTRATIVE FEES | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 930676 |
| Policy instance | 4 |
| Insurance contract or identification number | 930676 | | Number of Individuals Covered | 308 | | Insurance policy start date | 2018-12-01 | | Insurance policy end date | 2019-12-01 | | Total amount of commissions paid to insurance broker | USD $2,480 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | GROUP LONG TERM CARE | | Welfare Benefit Premiums Paid to Carrier | USD $15,452 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,480 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GVTL0AMCR |
| Policy instance | 5 |
| Insurance contract or identification number | GVTL0AMCR | | Number of Individuals Covered | 79 | | Insurance policy start date | 2018-09-01 | | Insurance policy end date | 2018-11-01 | | Total amount of commissions paid to insurance broker | USD $773 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $5,153 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $773 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG0AMCR |
| Policy instance | 6 |
| Insurance contract or identification number | GLUG0AMCR | | Number of Individuals Covered | 259 | | Insurance policy start date | 2018-09-01 | | Insurance policy end date | 2018-11-01 | | Total amount of commissions paid to insurance broker | USD $367 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $2,448 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $367 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUG0AMCR |
| Policy instance | 7 |
| Insurance contract or identification number | GUG0AMCR | | Number of Individuals Covered | 259 | | Insurance policy start date | 2018-09-01 | | Insurance policy end date | 2018-11-01 | | Total amount of commissions paid to insurance broker | USD $1,102 | | Total amount of fees paid to insurance company | USD $0 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $7,348 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,102 | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 930676 |
| Policy instance | 6 |
| Insurance contract or identification number | 930676 | | Number of Individuals Covered | 249 | | Insurance policy start date | 2017-09-01 | | Insurance policy end date | 2018-08-31 | | Total amount of commissions paid to insurance broker | USD $1,899 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | GROUP LONG TERM CARE | | Welfare Benefit Premiums Paid to Carrier | USD $12,657 | | 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 | GLTD0AMCR |
| Policy instance | 5 |
| Insurance contract or identification number | GLTD0AMCR | | Number of Individuals Covered | 260 | | Insurance policy start date | 2017-10-01 | | Insurance policy end date | 2018-09-30 | | Total amount of commissions paid to insurance broker | USD $7,975 | | Total amount of fees paid to insurance company | USD $1,027 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $53,170 | | 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 | GUG0AMCR |
| Policy instance | 4 |
| Insurance contract or identification number | GUG0AMCR | | Number of Individuals Covered | 260 | | Insurance policy start date | 2017-10-01 | | Insurance policy end date | 2018-09-30 | | Total amount of commissions paid to insurance broker | USD $4,200 | | Total amount of fees paid to insurance company | USD $523 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $27,997 | | 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 | GLUG0AMCR |
| Policy instance | 3 |
| Insurance contract or identification number | GLUG0AMCR | | Number of Individuals Covered | 259 | | Insurance policy start date | 2017-09-01 | | Insurance policy end date | 2018-08-31 | | Total amount of commissions paid to insurance broker | USD $2,073 | | Total amount of fees paid to insurance company | USD $272 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $13,822 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| BLUECROSS BLUESHIELD OF TENNESSEE, INC. (National Association of Insurance Commissioners NAIC id number: 54518 ) |
| Policy contract number | 115373 |
| Policy instance | 1 |
| Insurance contract or identification number | 115373 | | Number of Individuals Covered | 403 | | Insurance policy start date | 2017-09-01 | | Insurance policy end date | 2018-08-31 | | Total amount of commissions paid to insurance broker | USD $60,165 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,557,169 | | 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 | GVTL0AMCR |
| Policy instance | 2 |
| Insurance contract or identification number | GVTL0AMCR | | Number of Individuals Covered | 22 | | Insurance policy start date | 2017-09-01 | | Insurance policy end date | 2018-08-31 | | Total amount of commissions paid to insurance broker | USD $1,260 | | Total amount of fees paid to insurance company | USD $267 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $8,399 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
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