INTERSTATE PACKAGING COMPANY has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan INTERSTATE PACKAGING COMPANY HEALTH AND DENTAL PLAN
401k plan membership statisitcs for INTERSTATE PACKAGING COMPANY HEALTH AND DENTAL PLAN
| BLUECROSS BLUESHIELD OF TENNESSEE, INC. (National Association of Insurance Commissioners NAIC id number: 54518 ) |
| Policy contract number | 119777 |
| Policy instance | 4 |
| Insurance contract or identification number | 119777 | | Number of Individuals Covered | 281 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $7,643 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $14,002 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,643 | | Additional information about fees paid to insurance broker | ACQ/RET | | Insurance broker organization code? | 3 |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 936364 |
| Policy instance | 3 |
| Insurance contract or identification number | 936364 | | Number of Individuals Covered | 144 | | Insurance policy start date | 2021-11-01 | | Insurance policy end date | 2022-10-31 | | Total amount of commissions paid to insurance broker | USD $14,417 | | Total amount of fees paid to insurance company | USD $1,382 | | Welfare Benefit Premiums Paid to Carrier | USD $288,334 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $11,955 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 1382 | | Additional information about fees paid to insurance broker | BONUS PAYMENT |
|
| NORTHWESTERN MUTUAL (National Association of Insurance Commissioners NAIC id number: 67091 ) |
| Policy contract number | 657323 |
| Policy instance | 2 |
| Insurance contract or identification number | 657323 | | Number of Individuals Covered | 21 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $3,830 | | Total amount of fees paid to insurance company | USD $881 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $24,422 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,192 | | Amount paid for insurance broker fees | 804 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
| Policy contract number | TM05393033 |
| Policy instance | 1 |
| Insurance contract or identification number | TM05393033 | | Number of Individuals Covered | 308 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $13,097 | | Total amount of fees paid to insurance company | USD $1,168 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACC D&D | | Welfare Benefit Premiums Paid to Carrier | USD $87,317 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $13,097 | | Amount paid for insurance broker fees | 1168 | | Additional information about fees paid to insurance broker | SUPPLEMENTAL COMPENSATION NON-MONETARY COMPENSATION | | Insurance broker organization code? | 3 |
|
| BLUECROSS BLUESHIELD OF TENNESSEE, INC. (National Association of Insurance Commissioners NAIC id number: 54518 ) |
| Policy contract number | 11977 |
| Policy instance | 1 |
| Insurance contract or identification number | 11977 | | Number of Individuals Covered | 281 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $7,814 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $13,067 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,610 | | Additional information about fees paid to insurance broker | ACQ/RET | | Insurance broker organization code? | 3 |
|
| USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 ) |
| Policy contract number | 111977701I |
| Policy instance | 2 |
| Insurance contract or identification number | 111977701I | | Number of Individuals Covered | 18 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $360 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENT | | Welfare Benefit Premiums Paid to Carrier | USD $3,541 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $149 | | Insurance broker organization code? | 3 |
|
| USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 ) |
| Policy contract number | 50003756 |
| Policy instance | 3 |
| Insurance contract or identification number | 50003756 | | Number of Individuals Covered | 57 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $303 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | VOLUNTARY AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $1,082 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $141 | | Insurance broker organization code? | 3 |
|
| USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 ) |
| Policy contract number | 111977701I |
| Policy instance | 4 |
| Insurance contract or identification number | 111977701I | | Number of Individuals Covered | 10 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $347 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Other welfare benefits provided | CANCER | | Welfare Benefit Premiums Paid to Carrier | USD $3,906 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $193 | | Insurance broker organization code? | 3 |
|
| USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 ) |
| Policy contract number | 111977701I |
| Policy instance | 5 |
| Insurance contract or identification number | 111977701I | | Number of Individuals Covered | 5 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $112 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | CRIT CARE | | Welfare Benefit Premiums Paid to Carrier | USD $1,239 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $50 | | Insurance broker organization code? | 3 |
|
| NORTHWESTERN MUTUAL (National Association of Insurance Commissioners NAIC id number: 67091 ) |
| Policy contract number | 657323 |
| Policy instance | 6 |
| Insurance contract or identification number | 657323 | | Number of Individuals Covered | 22 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $4,050 | | Total amount of fees paid to insurance company | USD $932 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $24,164 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,375 | | Amount paid for insurance broker fees | 851 | | Insurance broker organization code? | 3 |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 936364 |
| Policy instance | 7 |
| Insurance contract or identification number | 936364 | | Number of Individuals Covered | 142 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $14,470 | | Total amount of fees paid to insurance company | USD $1,709 | | Welfare Benefit Premiums Paid to Carrier | USD $289,399 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $14,470 | | Amount paid for insurance broker fees | 1709 | | Insurance broker organization code? | 3 |
|
| BLUECROSS BLUESHIELD OF TENNESSEE, INC. (National Association of Insurance Commissioners NAIC id number: 54518 ) |
| Policy contract number | 11977 |
| Policy instance | 1 |
| Insurance contract or identification number | 11977 | | Number of Individuals Covered | 243 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $6,504 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $12,517 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,366 | | Additional information about fees paid to insurance broker | ACQ/RET | | Insurance broker organization code? | 3 |
|
| USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 ) |
| Policy contract number | 50003756 |
| Policy instance | 2 |
| Insurance contract or identification number | 50003756 | | Number of Individuals Covered | 132 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $1,149 | | Total amount of fees paid to insurance company | USD $83 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $4,131 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $620 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 83 |
|
| USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 ) |
| Policy contract number | 50003756 |
| Policy instance | 3 |
| Insurance contract or identification number | 50003756 | | Number of Individuals Covered | 57 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $302 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | VOLUNTARY AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $1,077 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $162 | | Insurance broker organization code? | 3 |
|
| USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 ) |
| Policy contract number | 111977701I |
| Policy instance | 4 |
| Insurance contract or identification number | 111977701I | | Number of Individuals Covered | 14 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $450 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Other welfare benefits provided | CANCER | | Welfare Benefit Premiums Paid to Carrier | USD $4,995 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $250 | | Insurance broker organization code? | 3 |
|
| USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 ) |
| Policy contract number | 111977701I |
| Policy instance | 5 |
| Insurance contract or identification number | 111977701I | | Number of Individuals Covered | 23 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $404 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACC ELITE | | Welfare Benefit Premiums Paid to Carrier | USD $4,189 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $184 | | Insurance broker organization code? | 3 |
|
| USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 ) |
| Policy contract number | 111977701I |
| Policy instance | 6 |
| Insurance contract or identification number | 111977701I | | Number of Individuals Covered | 9 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $127 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | CRIT CARE | | Welfare Benefit Premiums Paid to Carrier | USD $1,340 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $54 | | Insurance broker organization code? | 3 |
|
| USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 ) |
| Policy contract number | 50003756 |
| Policy instance | 2 |
| Insurance contract or identification number | 50003756 | | Number of Individuals Covered | 151 | | Insurance policy start date | 2019-11-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $256 | | Total amount of fees paid to insurance company | USD $17 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $855 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $128 | | Amount paid for insurance broker fees | 17 | | Insurance broker organization code? | 3 |
|
| USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 ) |
| Policy contract number | 50003756 |
| Policy instance | 3 |
| Insurance contract or identification number | 50003756 | | Number of Individuals Covered | 59 | | Insurance policy start date | 2019-11-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $726 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $2,592 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $389 | | Insurance broker organization code? | 3 |
|
| USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 ) |
| Policy contract number | 50003756 |
| Policy instance | 4 |
| Insurance contract or identification number | 50003756 | | Number of Individuals Covered | 59 | | Insurance policy start date | 2019-11-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $56 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $200 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $30 | | Insurance broker organization code? | 3 |
|
| BLUECROSS BLUESHIELD OF TENNESSEE, INC. (National Association of Insurance Commissioners NAIC id number: 54518 ) |
| Policy contract number | 119777 |
| Policy instance | 1 |
| Insurance contract or identification number | 119777 | | Number of Individuals Covered | 279 | | Insurance policy start date | 2019-11-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $1,710 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $2,525 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,710 | | Additional information about fees paid to insurance broker | ACQ/RET | | Insurance broker organization code? | 3 |
|
| BLUECROSS BLUESHIELD OF TENNESSEE, INC. (National Association of Insurance Commissioners NAIC id number: 54518 ) |
| Policy contract number | 119777 |
| Policy instance | 1 |
| Insurance contract or identification number | 119777 | | Number of Individuals Covered | 279 | | Insurance policy start date | 2018-11-01 | | Insurance policy end date | 2019-10-31 | | Total amount of commissions paid to insurance broker | USD $10,894 | | 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 $10,894 | | Additional information about fees paid to insurance broker | ACQ/RET | | Insurance broker organization code? | 3 |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 212612 |
| Policy instance | 7 |
| Insurance contract or identification number | 212612 | | Number of Individuals Covered | 181 | | Insurance policy start date | 2017-11-01 | | Insurance policy end date | 2018-10-31 | | Total amount of commissions paid to insurance broker | USD $6,599 | | Total amount of fees paid to insurance company | USD $0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $32,995 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 0906301 |
| Policy instance | 10 |
| Insurance contract or identification number | 0906301 | | Number of Individuals Covered | 264 | | Insurance policy start date | 2017-11-01 | | Insurance policy end date | 2018-10-31 | | Total amount of commissions paid to insurance broker | USD $1,297 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $12,968 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| NORTHWESTERN MUTUAL (National Association of Insurance Commissioners NAIC id number: 67091 ) |
| Policy contract number | 657323 |
| Policy instance | 9 |
| Insurance contract or identification number | 657323 | | Number of Individuals Covered | 22 | | Insurance policy start date | 2017-11-01 | | Insurance policy end date | 2018-10-31 | | Total amount of commissions paid to insurance broker | USD $3,596 | | Total amount of fees paid to insurance company | USD $907 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $24,823 | | 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 | 119777 |
| Policy instance | 1 |
| Insurance contract or identification number | 119777 | | Number of Individuals Covered | 268 | | Insurance policy start date | 2017-11-01 | | Insurance policy end date | 2018-10-31 | | Total amount of commissions paid to insurance broker | USD $66,186 | | 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 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 212612 |
| Policy instance | 2 |
| Insurance contract or identification number | 212612 | | Number of Individuals Covered | 181 | | Insurance policy start date | 2017-11-01 | | Insurance policy end date | 2018-10-31 | | Total amount of commissions paid to insurance broker | USD $1,150 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $12,420 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 212612 |
| Policy instance | 3 |
| Insurance contract or identification number | 212612 | | Number of Individuals Covered | 181 | | Insurance policy start date | 2017-11-01 | | Insurance policy end date | 2018-10-31 | | Total amount of commissions paid to insurance broker | USD $2,941 | | Total amount of fees paid to insurance company | USD $0 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $29,406 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 ) |
| Policy contract number | 50003756 |
| Policy instance | 4 |
| Insurance contract or identification number | 50003756 | | Number of Individuals Covered | 152 | | Insurance policy start date | 2017-11-01 | | Insurance policy end date | 2018-10-31 | | Total amount of commissions paid to insurance broker | USD $1,509 | | Total amount of fees paid to insurance company | USD $116 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $5,783 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 212612 |
| Policy instance | 8 |
| Insurance contract or identification number | 212612 | | Number of Individuals Covered | 181 | | Insurance policy start date | 2017-11-01 | | Insurance policy end date | 2018-10-31 | | Total amount of commissions paid to insurance broker | USD $128 | | Total amount of fees paid to insurance company | USD $0 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,380 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 ) |
| Policy contract number | 50003756 |
| Policy instance | 6 |
| Insurance contract or identification number | 50003756 | | Number of Individuals Covered | 77 | | Insurance policy start date | 2017-11-01 | | Insurance policy end date | 2018-10-31 | | Total amount of commissions paid to insurance broker | USD $5,520 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $19,713 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 ) |
| Policy contract number | 50003756 |
| Policy instance | 5 |
| Insurance contract or identification number | 50003756 | | Number of Individuals Covered | 77 | | Insurance policy start date | 2017-11-01 | | Insurance policy end date | 2018-10-31 | | Total amount of commissions paid to insurance broker | USD $439 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,569 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 ) |
| Policy contract number | 50003756 |
| Policy instance | 6 |
| Insurance contract or identification number | 50003756 | | Number of Individuals Covered | 109 | | Insurance policy start date | 2014-11-01 | | Insurance policy end date | 2015-10-31 | | Total amount of commissions paid to insurance broker | USD $5,391 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $19,252 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,888 | | Insurance broker organization code? | 3 | | Insurance broker name | GROUP INSURANCE SERVICES INC. |
|
| USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 ) |
| Policy contract number | 50003756 |
| Policy instance | 4 |
| Insurance contract or identification number | 50003756 | | Number of Individuals Covered | 132 | | Insurance policy start date | 2014-11-01 | | Insurance policy end date | 2015-10-31 | | Total amount of commissions paid to insurance broker | USD $1,152 | | Total amount of fees paid to insurance company | USD $87 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $4,328 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $649 | | Amount paid for insurance broker fees | 87 | | Insurance broker organization code? | 3 | | Insurance broker name | GROUP INSURANCE SERVICES INC. |
|
| USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 ) |
| Policy contract number | 50003756 |
| Policy instance | 5 |
| Insurance contract or identification number | 50003756 | | Number of Individuals Covered | 107 | | Insurance policy start date | 2014-11-01 | | Insurance policy end date | 2015-10-31 | | Total amount of commissions paid to insurance broker | USD $463 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,651 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $248 | | Insurance broker organization code? | 3 | | Insurance broker name | GROUP INSURANCE SERVICES INC. |
|
| BLUECROSS BLUESHIELD OF TENNESSEE, INC. (National Association of Insurance Commissioners NAIC id number: 54518 ) |
| Policy contract number | 119777 |
| Policy instance | 1 |
| Insurance contract or identification number | 119777 | | Number of Individuals Covered | 267 | | Insurance policy start date | 2014-11-01 | | Insurance policy end date | 2015-10-31 | | Total amount of commissions paid to insurance broker | USD $64,711 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,164,611 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $64,711 | | Additional information about fees paid to insurance broker | ACQ/RET | | Insurance broker organization code? | 3 | | Insurance broker name | KENNETH RIDEOUT |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 212612 |
| Policy instance | 2 |
| Insurance contract or identification number | 212612 | | Number of Individuals Covered | 144 | | Insurance policy start date | 2014-11-01 | | Insurance policy end date | 2015-10-31 | | Total amount of commissions paid to insurance broker | USD $290 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $11,831 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $290 | | Insurance broker name | DONALD HURWITZ |
|
| USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 ) |
| Policy contract number | 111977701 |
| Policy instance | 7 |
| Insurance contract or identification number | 111977701 | | Number of Individuals Covered | 52 | | Insurance policy start date | 2014-11-01 | | Insurance policy end date | 2015-10-31 | | Total amount of commissions paid to insurance broker | USD $1,999 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $9,683 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $765 | | Insurance broker organization code? | 3 | | Insurance broker name | KENNETH RIDEOUT |
|
| USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 ) |
| Policy contract number | 111977701 |
| Policy instance | 8 |
| Insurance contract or identification number | 111977701 | | Number of Individuals Covered | 39 | | Insurance policy start date | 2014-11-01 | | Insurance policy end date | 2015-10-31 | | Total amount of commissions paid to insurance broker | USD $2,264 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Other welfare benefits provided | CANCER INSURANCE | | Welfare Benefit Premiums Paid to Carrier | USD $12,177 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $935 | | Insurance broker organization code? | 3 | | Insurance broker name | KENNETH RIDEOUT |
|
| USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 ) |
| Policy contract number | 111977701 |
| Policy instance | 9 |
| Insurance contract or identification number | 111977701 | | Number of Individuals Covered | 24 | | Insurance policy start date | 2014-11-01 | | Insurance policy end date | 2015-10-31 | | Total amount of commissions paid to insurance broker | USD $600 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Other welfare benefits provided | CRITICAL CARE INSURANCE | | Welfare Benefit Premiums Paid to Carrier | USD $3,309 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $221 | | Insurance broker organization code? | 3 | | Insurance broker name | |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 212612 |
| Policy instance | 10 |
| Insurance contract or identification number | 212612 | | Number of Individuals Covered | 83 | | Insurance policy start date | 2014-11-01 | | Insurance policy end date | 2015-10-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $18,328 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 212612 |
| Policy instance | 3 |
| Insurance contract or identification number | 212612 | | Number of Individuals Covered | 125 | | Insurance policy start date | 2014-11-01 | | Insurance policy end date | 2015-10-31 | | Total amount of commissions paid to insurance broker | USD $892 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $23,167 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $892 | | Insurance broker organization code? | 3 | | Insurance broker name | DONALD HURWITZ |
|
| USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 ) |
| Policy contract number | 50003756 |
| Policy instance | 4 |
| Insurance contract or identification number | 50003756 | | Number of Individuals Covered | 125 | | Insurance policy start date | 2013-11-01 | | Insurance policy end date | 2014-10-31 | | Total amount of commissions paid to insurance broker | USD $1,032 | | Total amount of fees paid to insurance company | USD $76 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $3,782 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $567 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 76 | | Additional information about fees paid to insurance broker | BONUS | | Insurance broker name | GROUP INSURANCE SERVICES INC. |
|
| USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 ) |
| Policy contract number | 50003756 |
| Policy instance | 5 |
| Insurance contract or identification number | 50003756 | | Number of Individuals Covered | 112 | | Insurance policy start date | 2013-11-01 | | Insurance policy end date | 2014-10-31 | | Total amount of commissions paid to insurance broker | USD $486 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,736 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $260 | | Insurance broker organization code? | 3 | | Insurance broker name | GROUP INSURANCE SERVICES INC. |
|
| USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 ) |
| Policy contract number | 111977701 |
| Policy instance | 7 |
| Insurance contract or identification number | 111977701 | | Number of Individuals Covered | 50 | | Insurance policy start date | 2013-11-01 | | Insurance policy end date | 2014-10-31 | | Total amount of commissions paid to insurance broker | USD $1,912 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $11,125 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $787 | | Insurance broker organization code? | 3 | | Insurance broker name | ANTON FROELICH |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 212612 |
| Policy instance | 3 |
| Insurance contract or identification number | 212612 | | Number of Individuals Covered | 121 | | Insurance policy start date | 2014-02-01 | | Insurance policy end date | 2015-01-31 | | Total amount of commissions paid to insurance broker | USD $3,091 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $20,608 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,091 | | Insurance broker organization code? | 3 | | Insurance broker name | DONALD HURWITZ |
|
| BLUECROSS BLUESHIELD OF TENNESSEE, INC. (National Association of Insurance Commissioners NAIC id number: 54518 ) |
| Policy contract number | 119777 |
| Policy instance | 1 |
| Insurance contract or identification number | 119777 | | Number of Individuals Covered | 241 | | Insurance policy start date | 2013-11-01 | | Insurance policy end date | 2014-10-31 | | Total amount of commissions paid to insurance broker | USD $61,515 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,108,175 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $61,515 | | Additional information about fees paid to insurance broker | ACQ/RET | | Insurance broker organization code? | 3 | | Insurance broker name | KENNETH RIDEOUT |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 212612 |
| Policy instance | 2 |
| Insurance contract or identification number | 212612 | | Number of Individuals Covered | 141 | | Insurance policy start date | 2014-02-01 | | Insurance policy end date | 2015-01-31 | | Total amount of commissions paid to insurance broker | USD $1,085 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $10,620 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,085 | | Insurance broker organization code? | 3 | | Insurance broker name | DONALD HURWITZ |
|
| USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 ) |
| Policy contract number | 50003756 |
| Policy instance | 6 |
| Insurance contract or identification number | 50003756 | | Number of Individuals Covered | 115 | | Insurance policy start date | 2013-11-01 | | Insurance policy end date | 2014-10-31 | | Total amount of commissions paid to insurance broker | USD $5,143 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $18,367 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,755 | | Insurance broker organization code? | 3 | | Insurance broker name | GROUP INSURANCE SERVICES INC. |
|
| USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 ) |
| Policy contract number | 111977701 |
| Policy instance | 8 |
| Insurance contract or identification number | 111977701 | | Number of Individuals Covered | 39 | | Insurance policy start date | 2013-11-01 | | Insurance policy end date | 2014-10-31 | | Total amount of commissions paid to insurance broker | USD $1,921 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Other welfare benefits provided | CANCER INSURANCE | | Welfare Benefit Premiums Paid to Carrier | USD $11,864 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $841 | | Insurance broker organization code? | 3 | | Insurance broker name | JOHN HOUSTON |
|
| USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 ) |
| Policy contract number | 111977701 |
| Policy instance | 9 |
| Insurance contract or identification number | 111977701 | | Number of Individuals Covered | 20 | | Insurance policy start date | 2013-11-01 | | Insurance policy end date | 2014-10-31 | | Total amount of commissions paid to insurance broker | USD $448 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Other welfare benefits provided | CRITICAL CARE INSURANCE | | Welfare Benefit Premiums Paid to Carrier | USD $3,201 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $224 | | Insurance broker organization code? | 3 | | Insurance broker name | ANTON FROELICH |
|
| BLUECROSS BLUESHIELD OF TENNESSEE, INC. (National Association of Insurance Commissioners NAIC id number: 54518 ) |
| Policy contract number | 119777 |
| Policy instance | 1 |
| Insurance contract or identification number | 119777 | | Number of Individuals Covered | 228 | | Insurance policy start date | 2012-11-01 | | Insurance policy end date | 2013-10-31 | | Total amount of commissions paid to insurance broker | USD $56,950 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,027,724 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $52,385 | | Additional information about fees paid to insurance broker | ACQ/RET | | Insurance broker organization code? | 3 | | Insurance broker name | KENNETH RIDEOUT |
|
| COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 ) |
| Policy contract number | E3297017 |
| Policy instance | 2 |
| Insurance contract or identification number | E3297017 | | Number of Individuals Covered | 28 | | Insurance policy start date | 2012-11-01 | | Insurance policy end date | 2013-10-31 | | Total amount of commissions paid to insurance broker | USD $778 | | Total amount of fees paid to insurance company | USD $99 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $3,205 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $313 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 72 | | Additional information about fees paid to insurance broker | BONUS | | Insurance broker name | CHRISTOPHER MATTHEW TOWNSEND |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 212612 |
| Policy instance | 3 |
| Insurance contract or identification number | 212612 | | Number of Individuals Covered | 139 | | Insurance policy start date | 2013-02-01 | | Insurance policy end date | 2014-01-31 | | Total amount of commissions paid to insurance broker | USD $1,084 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $10,567 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,084 | | Insurance broker organization code? | 3 | | Insurance broker name | DONALD HURWITZ |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 212612 |
| Policy instance | 4 |
| Insurance contract or identification number | 212612 | | Number of Individuals Covered | 118 | | Insurance policy start date | 2013-02-01 | | Insurance policy end date | 2014-01-31 | | Total amount of commissions paid to insurance broker | USD $2,937 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $19,583 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,937 | | Insurance broker organization code? | 3 | | Insurance broker name | DONALD HURWITZ |
|
| USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 ) |
| Policy contract number | 50003756 |
| Policy instance | 5 |
| Insurance contract or identification number | 50003756 | | Number of Individuals Covered | 113 | | Insurance policy start date | 2012-11-01 | | Insurance policy end date | 2013-10-31 | | Total amount of commissions paid to insurance broker | USD $972 | | Total amount of fees paid to insurance company | USD $70 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $3,508 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $526 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 70 | | Additional information about fees paid to insurance broker | BONUS | | Insurance broker name | GROUP INSURANCE SERVICES INC. |
|
| USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 ) |
| Policy contract number | 50003756 |
| Policy instance | 6 |
| Insurance contract or identification number | 50003756 | | Number of Individuals Covered | 118 | | Insurance policy start date | 2012-11-01 | | Insurance policy end date | 2013-10-31 | | Total amount of commissions paid to insurance broker | USD $509 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,817 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $236 | | Insurance broker organization code? | 3 | | Insurance broker name | CBIZ BENEFITS & INSURANCE SERVICES |
|
| USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 ) |
| Policy contract number | 50003756 |
| Policy instance | 7 |
| Insurance contract or identification number | 50003756 | | Number of Individuals Covered | 121 | | Insurance policy start date | 2012-11-01 | | Insurance policy end date | 2013-10-31 | | Total amount of commissions paid to insurance broker | USD $4,930 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $17,610 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,289 | | Insurance broker organization code? | 3 | | Insurance broker name | CBIZ BENEFITS & INSURANCE SERVICES |
|
| USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 ) |
| Policy contract number | 111977701 |
| Policy instance | 8 |
| Insurance contract or identification number | 111977701 | | Number of Individuals Covered | 64 | | Insurance policy start date | 2012-11-01 | | Insurance policy end date | 2013-10-31 | | Total amount of commissions paid to insurance broker | USD $4,535 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $12,318 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,205 | | Insurance broker organization code? | 3 | | Insurance broker name | ANTON FROELICH |
|
| USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 ) |
| Policy contract number | 111977701 |
| Policy instance | 9 |
| Insurance contract or identification number | 111977701 | | Number of Individuals Covered | 45 | | Insurance policy start date | 2012-11-01 | | Insurance policy end date | 2013-10-31 | | Total amount of commissions paid to insurance broker | USD $3,771 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Other welfare benefits provided | CANCER INSURANCE | | Welfare Benefit Premiums Paid to Carrier | USD $12,318 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,121 | | Insurance broker organization code? | 3 | | Insurance broker name | JOHN HOUSTON |
|
| USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 ) |
| Policy contract number | 111977701 |
| Policy instance | 10 |
| Insurance contract or identification number | 111977701 | | Number of Individuals Covered | 25 | | Insurance policy start date | 2012-11-01 | | Insurance policy end date | 2013-10-31 | | Total amount of commissions paid to insurance broker | USD $1,219 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Other welfare benefits provided | CRITICAL CARE INSURANCE | | Welfare Benefit Premiums Paid to Carrier | USD $3,291 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $593 | | Insurance broker organization code? | 3 | | Insurance broker name | ANTON FROELICH |
|
| COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 ) |
| Policy contract number | E3297017 |
| Policy instance | 2 |
| Insurance contract or identification number | E3297017 | | Number of Individuals Covered | 28 | | Insurance policy start date | 2011-11-01 | | Insurance policy end date | 2012-10-31 | | Total amount of commissions paid to insurance broker | USD $4,481 | | Total amount of fees paid to insurance company | USD $676 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $18,357 | | 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 | 119777 |
| Policy instance | 1 |
| Insurance contract or identification number | 119777 | | Number of Individuals Covered | 223 | | Insurance policy start date | 2011-11-01 | | Insurance policy end date | 2012-10-31 | | Total amount of commissions paid to insurance broker | USD $50,202 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,154,715 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 ) |
| Policy contract number | E3297017 |
| Policy instance | 2 |
| Insurance contract or identification number | E3297017 | | Number of Individuals Covered | 30 | | Insurance policy start date | 2010-11-01 | | Insurance policy end date | 2011-10-31 | | Total amount of commissions paid to insurance broker | USD $1,424 | | Total amount of fees paid to insurance company | USD $68 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $15,329 | | 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 | 119777 |
| Policy instance | 1 |
| Insurance contract or identification number | 119777 | | Number of Individuals Covered | 224 | | Insurance policy start date | 2010-11-01 | | Insurance policy end date | 2011-10-31 | | Total amount of commissions paid to insurance broker | USD $49,991 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,105,457 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
