RUBBER & GASKET COMPANY OF AMERICA, INC. has sponsored the creation of one or more 401k plans.
Additional information about RUBBER & GASKET COMPANY OF AMERICA, INC.
Submission information for form 5500 for 401k plan RUBBER & GASKET COMPANY OF AMERICA EMPLOYEE HEALTH
401k plan membership statisitcs for RUBBER & GASKET COMPANY OF AMERICA EMPLOYEE HEALTH
| Measure | Date | Value |
|---|
| 2023: RUBBER & GASKET COMPANY OF AMERICA EMPLOYEE HEALTH 2023 401k membership |
|---|
| Total participants, beginning-of-year | 2023-02-01 | 142 |
| Total number of active participants reported on line 7a of the Form 5500 | 2023-02-01 | 145 |
| Total of all active and inactive participants | 2023-02-01 | 145 |
| 2022: RUBBER & GASKET COMPANY OF AMERICA EMPLOYEE HEALTH 2022 401k membership |
|---|
| Total participants, beginning-of-year | 2022-02-01 | 192 |
| Total number of active participants reported on line 7a of the Form 5500 | 2022-02-01 | 142 |
| Total of all active and inactive participants | 2022-02-01 | 142 |
| 2021: RUBBER & GASKET COMPANY OF AMERICA EMPLOYEE HEALTH 2021 401k membership |
|---|
| Total participants, beginning-of-year | 2021-02-01 | 134 |
| Total number of active participants reported on line 7a of the Form 5500 | 2021-02-01 | 192 |
| Total of all active and inactive participants | 2021-02-01 | 192 |
| 2020: RUBBER & GASKET COMPANY OF AMERICA EMPLOYEE HEALTH 2020 401k membership |
|---|
| Total participants, beginning-of-year | 2020-02-01 | 127 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-02-01 | 134 |
| Number of retired or separated participants receiving benefits | 2020-02-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2020-02-01 | 0 |
| Total of all active and inactive participants | 2020-02-01 | 134 |
| 2019: RUBBER & GASKET COMPANY OF AMERICA EMPLOYEE HEALTH 2019 401k membership |
|---|
| Total participants, beginning-of-year | 2019-02-01 | 111 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-02-01 | 127 |
| Number of retired or separated participants receiving benefits | 2019-02-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2019-02-01 | 0 |
| Total of all active and inactive participants | 2019-02-01 | 127 |
| 2018: RUBBER & GASKET COMPANY OF AMERICA EMPLOYEE HEALTH 2018 401k membership |
|---|
| Total participants, beginning-of-year | 2018-02-01 | 111 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-02-01 | 111 |
| Number of retired or separated participants receiving benefits | 2018-02-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2018-02-01 | 0 |
| Total of all active and inactive participants | 2018-02-01 | 111 |
| 2017: RUBBER & GASKET COMPANY OF AMERICA EMPLOYEE HEALTH 2017 401k membership |
|---|
| Total participants, beginning-of-year | 2017-02-01 | 105 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-02-01 | 105 |
| Number of retired or separated participants receiving benefits | 2017-02-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2017-02-01 | 0 |
| Total of all active and inactive participants | 2017-02-01 | 105 |
| 2016: RUBBER & GASKET COMPANY OF AMERICA EMPLOYEE HEALTH 2016 401k membership |
|---|
| Total participants, beginning-of-year | 2016-02-01 | 104 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-02-01 | 104 |
| Number of retired or separated participants receiving benefits | 2016-02-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2016-02-01 | 0 |
| Total of all active and inactive participants | 2016-02-01 | 104 |
| 2015: RUBBER & GASKET COMPANY OF AMERICA EMPLOYEE HEALTH 2015 401k membership |
|---|
| Total participants, beginning-of-year | 2015-02-01 | 99 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-02-01 | 104 |
| Total of all active and inactive participants | 2015-02-01 | 104 |
| Total participants | 2015-02-01 | 104 |
| 2014: RUBBER & GASKET COMPANY OF AMERICA EMPLOYEE HEALTH 2014 401k membership |
|---|
| Total participants, beginning-of-year | 2014-02-01 | 100 |
| Total number of active participants reported on line 7a of the Form 5500 | 2014-02-01 | 99 |
| Total of all active and inactive participants | 2014-02-01 | 99 |
| Total participants | 2014-02-01 | 99 |
| 2013: RUBBER & GASKET COMPANY OF AMERICA EMPLOYEE HEALTH 2013 401k membership |
|---|
| Total participants, beginning-of-year | 2013-02-01 | 97 |
| Total number of active participants reported on line 7a of the Form 5500 | 2013-02-01 | 100 |
| Total of all active and inactive participants | 2013-02-01 | 100 |
| Total participants | 2013-02-01 | 100 |
| 2012: RUBBER & GASKET COMPANY OF AMERICA EMPLOYEE HEALTH 2012 401k membership |
|---|
| Total participants, beginning-of-year | 2012-02-01 | 106 |
| Total number of active participants reported on line 7a of the Form 5500 | 2012-02-01 | 97 |
| Total of all active and inactive participants | 2012-02-01 | 97 |
| Total participants | 2012-02-01 | 97 |
| 2011: RUBBER & GASKET COMPANY OF AMERICA EMPLOYEE HEALTH 2011 401k membership |
|---|
| Total participants, beginning-of-year | 2011-02-01 | 55 |
| Total number of active participants reported on line 7a of the Form 5500 | 2011-02-01 | 106 |
| Number of retired or separated participants receiving benefits | 2011-02-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2011-02-01 | 0 |
| Total of all active and inactive participants | 2011-02-01 | 106 |
| 2009: RUBBER & GASKET COMPANY OF AMERICA EMPLOYEE HEALTH 2009 401k membership |
|---|
| Total participants, beginning-of-year | 2009-02-01 | 130 |
| Total number of active participants reported on line 7a of the Form 5500 | 2009-02-01 | 91 |
| Number of retired or separated participants receiving benefits | 2009-02-01 | 5 |
| Number of other retired or separated participants entitled to future benefits | 2009-02-01 | 0 |
| Total of all active and inactive participants | 2009-02-01 | 96 |
| Total participants | 2009-02-01 | 0 |
| USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 ) |
| Policy contract number | 50049486 |
| Policy instance | 11 |
| Insurance contract or identification number | 50049486 | | Number of Individuals Covered | 74 | | Insurance policy start date | 2023-02-01 | | Insurance policy end date | 2024-01-31 | | Total amount of commissions paid to insurance broker | USD $4,887 | | Total amount of fees paid to insurance company | USD $895 | | Other welfare benefits provided | VOL SHORT TERM DISABILITY | | Welfare Benefit Premiums Paid to Carrier | USD $22,221 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| ARKANSAS BLUE CROSS BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 83470 ) |
| Policy contract number | 029562 |
| Policy instance | 1 |
| Insurance contract or identification number | 029562 | | Number of Individuals Covered | 145 | | Insurance policy start date | 2023-02-01 | | Insurance policy end date | 2024-01-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| ARKANSAS BLUE CROSS BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 83470 ) |
| Policy contract number | 061892 |
| Policy instance | 2 |
| Insurance contract or identification number | 061892 | | Number of Individuals Covered | 128 | | Insurance policy start date | 2023-02-01 | | Insurance policy end date | 2024-01-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $22,305 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| ARKANSAS BLUE CROSS BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 83470 ) |
| Policy contract number | D00996 |
| Policy instance | 3 |
| Insurance contract or identification number | D00996 | | Number of Individuals Covered | 158 | | Insurance policy start date | 2023-02-01 | | Insurance policy end date | 2024-01-31 | | Total amount of commissions paid to insurance broker | USD $4,848 | | 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 |
|
| TRUSTMARK INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61425 ) |
| Policy contract number | 3000001618 |
| Policy instance | 4 |
| Insurance contract or identification number | 3000001618 | | Number of Individuals Covered | 42 | | Insurance policy start date | 2023-02-01 | | Insurance policy end date | 2024-01-31 | | Total amount of commissions paid to insurance broker | USD $4,447 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | GROUP HOSPITAL STAY PAY | | Welfare Benefit Premiums Paid to Carrier | USD $10,489 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| TRUSTMARK INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61425 ) |
| Policy contract number | 3000001618 |
| Policy instance | 5 |
| Insurance contract or identification number | 3000001618 | | Number of Individuals Covered | 33 | | Insurance policy start date | 2023-02-01 | | Insurance policy end date | 2024-01-31 | | Total amount of commissions paid to insurance broker | USD $4,438 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | GROUP CRITICAL HEALTH EVENTS | | Welfare Benefit Premiums Paid to Carrier | USD $9,922 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| TRUSTMARK INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61425 ) |
| Policy contract number | 3000001618 |
| Policy instance | 6 |
| Insurance contract or identification number | 3000001618 | | Number of Individuals Covered | 46 | | Insurance policy start date | 2023-02-01 | | Insurance policy end date | 2024-01-31 | | Total amount of commissions paid to insurance broker | USD $4,459 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | GROUP ACCIDENT | | Welfare Benefit Premiums Paid to Carrier | USD $9,658 | | 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 | 50049486 |
| Policy instance | 7 |
| Insurance contract or identification number | 50049486 | | Number of Individuals Covered | 175 | | Insurance policy start date | 2023-02-01 | | Insurance policy end date | 2024-01-31 | | Total amount of commissions paid to insurance broker | USD $741 | | Total amount of fees paid to insurance company | USD $284 | | Other welfare benefits provided | AD&D GROUP TERM LIFE | | Welfare Benefit Premiums Paid to Carrier | USD $7,099 | | 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 | 50049486 |
| Policy instance | 8 |
| Insurance contract or identification number | 50049486 | | Number of Individuals Covered | 185 | | Insurance policy start date | 2023-02-01 | | Insurance policy end date | 2024-01-31 | | Total amount of commissions paid to insurance broker | USD $929 | | Total amount of fees paid to insurance company | USD $185 | | Other welfare benefits provided | VOL AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $4,207 | | 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 | 50049486 |
| Policy instance | 9 |
| Insurance contract or identification number | 50049486 | | Number of Individuals Covered | 185 | | Insurance policy start date | 2023-02-01 | | Insurance policy end date | 2024-01-31 | | Total amount of commissions paid to insurance broker | USD $9,022 | | Total amount of fees paid to insurance company | USD $1,724 | | Other welfare benefits provided | VOL GROUP TERM LIFE | | Welfare Benefit Premiums Paid to Carrier | USD $40,892 | | 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 | 50049486 |
| Policy instance | 10 |
| Insurance contract or identification number | 50049486 | | Number of Individuals Covered | 69 | | Insurance policy start date | 2023-02-01 | | Insurance policy end date | 2024-01-31 | | Total amount of commissions paid to insurance broker | USD $4,035 | | Total amount of fees paid to insurance company | USD $738 | | Other welfare benefits provided | VOL LONG TERM DISABILITY | | 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 |
|
| ARKANSAS BLUE CROSS BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 83470 ) |
| Policy contract number | D00996 |
| Policy instance | 6 |
| Insurance contract or identification number | D00996 | | Number of Individuals Covered | 156 | | Insurance policy start date | 2022-09-01 | | Insurance policy end date | 2023-01-31 | | Total amount of commissions paid to insurance broker | USD $2,060 | | 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 $2,060 | | Insurance broker organization code? | 3 |
|
| ARKANSAS BLUE CROSS BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 83470 ) |
| Policy contract number | 061892 |
| Policy instance | 5 |
| Insurance contract or identification number | 061892 | | Number of Individuals Covered | 120 | | Insurance policy start date | 2022-09-01 | | Insurance policy end date | 2023-01-31 | | Total amount of commissions paid to insurance broker | USD $936 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $9,361 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $936 | | Insurance broker organization code? | 3 |
|
| ARKANSAS BLUE CROSS BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 83470 ) |
| Policy contract number | 029562 |
| Policy instance | 4 |
| Insurance contract or identification number | 029562 | | Number of Individuals Covered | 142 | | Insurance policy start date | 2022-09-01 | | Insurance policy end date | 2023-01-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 ) |
| Policy contract number | 1115702 |
| Policy instance | 3 |
| Insurance contract or identification number | 1115702 | | Number of Individuals Covered | 277 | | Insurance policy start date | 2022-02-01 | | Insurance policy end date | 2022-08-31 | | Total amount of commissions paid to insurance broker | USD $5,775 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $43,085 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,775 | | Insurance broker organization code? | 3 |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 927001 |
| Policy instance | 1 |
| Insurance contract or identification number | 927001 | | Number of Individuals Covered | 134 | | Insurance policy start date | 2022-02-01 | | Insurance policy end date | 2022-08-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $22,476 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $725,343 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $0 | | Amount paid for insurance broker fees | 22476 | | Additional information about fees paid to insurance broker | SERVICE FEE AGREEMENT | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL PLAN OF ARKANSAS (National Association of Insurance Commissioners NAIC id number: 47155 ) |
| Policy contract number | 000005608 |
| Policy instance | 2 |
| Insurance contract or identification number | 000005608 | | Number of Individuals Covered | 0 | | Insurance policy start date | 2022-02-01 | | Insurance policy end date | 2022-08-31 | | Total amount of commissions paid to insurance broker | USD $3,089 | | 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 $3,089 | | Insurance broker organization code? | 3 |
|
| TRUSTMARK INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61425 ) |
| Policy contract number | 3000001618 |
| Policy instance | 7 |
| Insurance contract or identification number | 3000001618 | | Number of Individuals Covered | 35 | | Insurance policy start date | 2022-09-01 | | Insurance policy end date | 2023-01-31 | | Total amount of commissions paid to insurance broker | USD $2,309 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | GROUP HOSPITAL STAY PAY | | Welfare Benefit Premiums Paid to Carrier | USD $4,198 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,309 | | Insurance broker organization code? | 3 |
|
| TRUSTMARK INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61425 ) |
| Policy contract number | 3000001618 |
| Policy instance | 8 |
| Insurance contract or identification number | 3000001618 | | Number of Individuals Covered | 33 | | Insurance policy start date | 2022-09-01 | | Insurance policy end date | 2023-01-31 | | Total amount of commissions paid to insurance broker | USD $2,632 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | GROUP CRITICAL HEALTH EVENTS | | Welfare Benefit Premiums Paid to Carrier | USD $4,386 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,632 | | Insurance broker organization code? | 3 |
|
| TRUSTMARK INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61425 ) |
| Policy contract number | 3000001618 |
| Policy instance | 9 |
| Insurance contract or identification number | 3000001618 | | Number of Individuals Covered | 49 | | Insurance policy start date | 2022-09-01 | | Insurance policy end date | 2023-01-31 | | Total amount of commissions paid to insurance broker | USD $2,406 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | GROUP ACCIDENT | | Welfare Benefit Premiums Paid to Carrier | USD $4,009 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,406 | | Insurance broker organization code? | 3 |
|
| USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 ) |
| Policy contract number | 50049486 |
| Policy instance | 10 |
| Insurance contract or identification number | 50049486 | | Number of Individuals Covered | 181 | | Insurance policy start date | 2022-09-01 | | Insurance policy end date | 2023-01-31 | | Total amount of commissions paid to insurance broker | USD $697 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | AD&D GROUP TERM LIFE | | Welfare Benefit Premiums Paid to Carrier | USD $3,015 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $354 | | Insurance broker organization code? | 3 |
|
| USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 ) |
| Policy contract number | 50049486 |
| Policy instance | 11 |
| Insurance contract or identification number | 50049486 | | Number of Individuals Covered | 196 | | Insurance policy start date | 2022-09-01 | | Insurance policy end date | 2023-01-31 | | Total amount of commissions paid to insurance broker | USD $641 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | VOL AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $1,850 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $370 | | Insurance broker organization code? | 3 |
|
| USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 ) |
| Policy contract number | 50049486 |
| Policy instance | 12 |
| Insurance contract or identification number | 50049486 | | Number of Individuals Covered | 196 | | Insurance policy start date | 2022-09-01 | | Insurance policy end date | 2023-01-31 | | Total amount of commissions paid to insurance broker | USD $6,058 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | VOL GROUP TERM LIFE | | Welfare Benefit Premiums Paid to Carrier | USD $17,544 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,509 | | Insurance broker organization code? | 3 |
|
| USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 ) |
| Policy contract number | 50049486 |
| Policy instance | 13 |
| Insurance contract or identification number | 50049486 | | Number of Individuals Covered | 62 | | Insurance policy start date | 2022-09-01 | | Insurance policy end date | 2023-01-31 | | Total amount of commissions paid to insurance broker | USD $2,542 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | VOL LONG TERM DISABILITY | | Welfare Benefit Premiums Paid to Carrier | USD $7,364 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,473 | | Insurance broker organization code? | 3 |
|
| USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 ) |
| Policy contract number | 50049486 |
| Policy instance | 14 |
| Insurance contract or identification number | 50049486 | | Number of Individuals Covered | 80 | | Insurance policy start date | 2022-09-01 | | Insurance policy end date | 2023-01-31 | | Total amount of commissions paid to insurance broker | USD $3,074 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | VOL SHORT TERM DISABILITY | | Welfare Benefit Premiums Paid to Carrier | USD $8,893 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,779 | | Insurance broker organization code? | 3 |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 08F1694 |
| Policy instance | 1 |
| Insurance contract or identification number | 08F1694 | | Number of Individuals Covered | 192 | | Insurance policy start date | 2021-02-01 | | Insurance policy end date | 2022-01-31 | | Total amount of commissions paid to insurance broker | USD $33,711 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,124,671 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $33,711 | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL PLAN OF ARKANSAS (National Association of Insurance Commissioners NAIC id number: 47155 ) |
| Policy contract number | 000005608 |
| Policy instance | 2 |
| Insurance contract or identification number | 000005608 | | Number of Individuals Covered | 296 | | Insurance policy start date | 2021-02-01 | | Insurance policy end date | 2022-01-31 | | Total amount of commissions paid to insurance broker | USD $4,157 | | 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 $4,157 | | Insurance broker organization code? | 3 |
|
| PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 ) |
| Policy contract number | 1115702 |
| Policy instance | 3 |
| Insurance contract or identification number | 1115702 | | Number of Individuals Covered | 263 | | Insurance policy start date | 2021-02-01 | | Insurance policy end date | 2022-01-31 | | Total amount of commissions paid to insurance broker | USD $8,081 | | Total amount of fees paid to insurance company | USD $649 | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | INDEMNITY CONTRACT | | Welfare Benefit Premiums Paid to Carrier | USD $64,490 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,081 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 649 | | Additional information about fees paid to insurance broker | BONUS |
|
| PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 ) |
| Policy contract number | 1115702 |
| Policy instance | 3 |
| Insurance contract or identification number | 1115702 | | Number of Individuals Covered | 262 | | Insurance policy start date | 2020-02-01 | | Insurance policy end date | 2021-01-31 | | Total amount of commissions paid to insurance broker | USD $8,002 | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $63,899 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,704 | | Insurance broker organization code? | 3 |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 08F1694 |
| Policy instance | 2 |
| Insurance contract or identification number | 08F1694 | | Number of Individuals Covered | 195 | | Insurance policy start date | 2020-02-01 | | Insurance policy end date | 2021-01-31 | | Total amount of commissions paid to insurance broker | USD $33,970 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,133,321 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $33,970 | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL PLAN OF ARKANSAS (National Association of Insurance Commissioners NAIC id number: 47155 ) |
| Policy contract number | 000005608 |
| Policy instance | 1 |
| Insurance contract or identification number | 000005608 | | Number of Individuals Covered | 300 | | Insurance policy start date | 2020-02-01 | | Insurance policy end date | 2021-01-31 | | Total amount of commissions paid to insurance broker | USD $3,501 | | 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 $3,501 | | Insurance broker organization code? | 3 |
|
| PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 ) |
| Policy contract number | 1115702 |
| Policy instance | 5 |
| Insurance contract or identification number | 1115702 | | Number of Individuals Covered | 257 | | Insurance policy start date | 2019-09-01 | | Insurance policy end date | 2020-01-31 | | Total amount of commissions paid to insurance broker | USD $3,172 | | Total amount of fees paid to insurance company | USD $1,804 | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $25,419 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,172 | | Amount paid for insurance broker fees | 1804 | | Insurance broker organization code? | 3 |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 08F1694 |
| Policy instance | 4 |
| Insurance contract or identification number | 08F1694 | | Number of Individuals Covered | 189 | | Insurance policy start date | 2019-09-01 | | Insurance policy end date | 2020-01-31 | | Total amount of commissions paid to insurance broker | USD $14,044 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $468,549 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $14,044 | | Insurance broker organization code? | 3 |
|
| ARKANSAS BLUE CROSS BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 83470 ) |
| Policy contract number | 028483 |
| Policy instance | 3 |
| Insurance contract or identification number | 028483 | | Insurance policy start date | 2019-02-01 | | Insurance policy end date | 2020-01-31 | | Health Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| DELTA DENTAL PLAN OF ARKANSAS (National Association of Insurance Commissioners NAIC id number: 47155 ) |
| Policy contract number | 000005608 |
| Policy instance | 2 |
| Insurance contract or identification number | 000005608 | | Number of Individuals Covered | 294 | | Insurance policy start date | 2019-02-01 | | Insurance policy end date | 2020-01-31 | | Total amount of commissions paid to insurance broker | USD $3,865 | | 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 $3,865 | | Insurance broker organization code? | 3 |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 00470562 |
| Policy instance | 1 |
| Insurance contract or identification number | 00470562 | | Number of Individuals Covered | 149 | | Insurance policy start date | 2019-02-01 | | Insurance policy end date | 2020-01-31 | | Total amount of commissions paid to insurance broker | USD $3,641 | | Total amount of fees paid to insurance company | USD $3,181 | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,641 | | Amount paid for insurance broker fees | 3181 | | Insurance broker organization code? | 3 |
|
| ARKANSAS BLUE CROSS BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 83470 ) |
| Policy contract number | 028483 |
| Policy instance | 3 |
| Insurance contract or identification number | 028483 | | Number of Individuals Covered | 185 | | Insurance policy start date | 2018-02-01 | | Insurance policy end date | 2019-01-31 | | Total amount of commissions paid to insurance broker | USD $40,347 | | Health Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $40,347 | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL PLAN OF ARKANSAS (National Association of Insurance Commissioners NAIC id number: 47155 ) |
| Policy contract number | 000005608 |
| Policy instance | 2 |
| Insurance contract or identification number | 000005608 | | Number of Individuals Covered | 275 | | Insurance policy start date | 2018-02-01 | | Insurance policy end date | 2019-01-31 | | Total amount of commissions paid to insurance broker | USD $3,853 | | 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 $3,853 | | Insurance broker organization code? | 3 |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 00470562 |
| Policy instance | 1 |
| Insurance contract or identification number | 00470562 | | Number of Individuals Covered | 129 | | Insurance policy start date | 2018-02-01 | | Insurance policy end date | 2019-01-31 | | Total amount of commissions paid to insurance broker | USD $6,805 | | Total amount of fees paid to insurance company | USD $3,413 | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,746 | | Amount paid for insurance broker fees | 3413 | | Insurance broker organization code? | 3 |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 00470562 |
| Policy instance | 1 |
| Insurance contract or identification number | 00470562 | | Number of Individuals Covered | 107 | | Insurance policy start date | 2017-02-01 | | Insurance policy end date | 2018-01-31 | | Total amount of commissions paid to insurance broker | USD $6,025 | | Total amount of fees paid to insurance company | USD $3,029 | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,468 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 3029 | | Insurance broker name | GALLAGHER BENEFIT SERVICES INC |
|
| ARKANSAS BLUE CROSS BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 83470 ) |
| Policy contract number | 028483 |
| Policy instance | 3 |
| Insurance contract or identification number | 028483 | | Number of Individuals Covered | 187 | | Insurance policy start date | 2017-02-01 | | Insurance policy end date | 2018-01-31 | | Total amount of fees paid to insurance company | USD $32,232 | | Health Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 32232 | | Insurance broker organization code? | 3 | | Insurance broker name | GALLAGHER BENEFIT SERVICES INC |
|
| DELTA DENTAL PLAN OF ARKANSAS (National Association of Insurance Commissioners NAIC id number: 47155 ) |
| Policy contract number | 000005608 |
| Policy instance | 2 |
| Insurance contract or identification number | 000005608 | | Number of Individuals Covered | 271 | | Insurance policy start date | 2017-02-01 | | Insurance policy end date | 2018-01-31 | | Total amount of commissions paid to insurance broker | USD $3,388 | | 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 $3,388 | | Insurance broker organization code? | 3 | | Insurance broker name | GALLAGHER BENEFIT SERVICES INC. |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 00470562 |
| Policy instance | 1 |
| Insurance contract or identification number | 00470562 | | Number of Individuals Covered | 109 | | Insurance policy start date | 2015-02-01 | | Insurance policy end date | 2016-01-31 | | Total amount of commissions paid to insurance broker | USD $6,140 | | Total amount of fees paid to insurance company | USD $3,142 | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,140 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 3142 | | Insurance broker name | WOODBURY FIN SVCS INC |
|
| DELTA DENTAL PLAN OF ARKANSAS (National Association of Insurance Commissioners NAIC id number: 47155 ) |
| Policy contract number | 000005608 |
| Policy instance | 2 |
| Insurance contract or identification number | 000005608 | | Number of Individuals Covered | 259 | | Insurance policy start date | 2015-02-01 | | Insurance policy end date | 2016-01-31 | | Total amount of commissions paid to insurance broker | USD $2,913 | | 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 $2,913 | | Insurance broker organization code? | 3 | | Insurance broker name | GALLAGHER BENEFIT SERVICES INC. |
|
| ARKANSAS BLUE CROSS BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 83470 ) |
| Policy contract number | 028483 |
| Policy instance | 3 |
| Insurance contract or identification number | 028483 | | Number of Individuals Covered | 171 | | Insurance policy start date | 2015-02-01 | | Insurance policy end date | 2016-01-31 | | Total amount of commissions paid to insurance broker | USD $22,433 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ABCBS HSA | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $22,433 | | Insurance broker organization code? | 3 | | Insurance broker name | GROUP BENEFITS OF ARKANSAS LLC |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 00470562 |
| Policy instance | 1 |
| Insurance contract or identification number | 00470562 | | Number of Individuals Covered | 108 | | Insurance policy start date | 2014-02-01 | | Insurance policy end date | 2015-01-31 | | Total amount of commissions paid to insurance broker | USD $5,708 | | Total amount of fees paid to insurance company | USD $1,266 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,608 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 1266 | | Insurance broker name | CHARTWELL FINANCIAL GROUP LLC |
|
| DELTA DENTAL PLAN OF ARKANSAS (National Association of Insurance Commissioners NAIC id number: 47155 ) |
| Policy contract number | 000005608 |
| Policy instance | 2 |
| Insurance contract or identification number | 000005608 | | Number of Individuals Covered | 250 | | Insurance policy start date | 2014-02-01 | | Insurance policy end date | 2015-01-31 | | Total amount of commissions paid to insurance broker | USD $3,211 | | 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 | | 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 $2,425 | | Insurance broker organization code? | 3 | | Insurance broker name | GALLAGHER BENEFIT SERVICES INC. |
|
| ARKANSAS BLUE CROSS BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 83470 ) |
| Policy contract number | 028483 |
| Policy instance | 3 |
| Insurance contract or identification number | 028483 | | Number of Individuals Covered | 159 | | Insurance policy start date | 2014-02-01 | | Insurance policy end date | 2015-01-31 | | Total amount of commissions paid to insurance broker | USD $21,279 | | 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 | | Other welfare benefits provided | ABCBS HSA | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $21,279 | | Insurance broker organization code? | 3 | | Insurance broker name | GROUP BENEFITS OF ARKANSAS LLC |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 00470562 |
| Policy instance | 1 |
| Insurance contract or identification number | 00470562 | | Number of Individuals Covered | 102 | | Insurance policy start date | 2013-02-01 | | Insurance policy end date | 2014-01-31 | | Total amount of commissions paid to insurance broker | USD $2,864 | | Total amount of fees paid to insurance company | USD $707 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Vision Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,787 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 707 | | Insurance broker name | CHARTWELL FINANCIAL GROUP LLC |
|
| DELTA DENTAL PLAN OF ARKANSAS (National Association of Insurance Commissioners NAIC id number: 47155 ) |
| Policy contract number | 000005608 |
| Policy instance | 2 |
| Insurance contract or identification number | 000005608 | | Number of Individuals Covered | 255 | | Insurance policy start date | 2013-02-01 | | Insurance policy end date | 2014-01-31 | | Total amount of commissions paid to insurance broker | USD $3,042 | | 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 | | 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 $3,042 | | Insurance broker organization code? | 3 | | Insurance broker name | GROUP BENEFITS OF ARKANAS LLC |
|
| ARKANSAS BLUE CROSS BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 83470 ) |
| Policy contract number | 028483 |
| Policy instance | 3 |
| Insurance contract or identification number | 028483 | | Number of Individuals Covered | 158 | | Insurance policy start date | 2013-02-01 | | Insurance policy end date | 2014-01-31 | | Total amount of commissions paid to insurance broker | USD $19,214 | | 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 | | Other welfare benefits provided | ABCBS HSA | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $19,214 | | Insurance broker organization code? | 3 | | Insurance broker name | GROUP BENEFITS OF ARKANAS LLC |
|
| DELTA DENTAL PLAN OF ARKANSAS (National Association of Insurance Commissioners NAIC id number: 47155 ) |
| Policy contract number | 000005608 |
| Policy instance | 1 |
| Insurance contract or identification number | 000005608 | | Number of Individuals Covered | 248 | | Insurance policy start date | 2012-02-01 | | Insurance policy end date | 2013-01-31 | | Total amount of commissions paid to insurance broker | USD $3,038 | | 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 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| ARKANSAS BLUE CROSS BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 83470 ) |
| Policy contract number | 028483 |
| Policy instance | 3 |
| Insurance contract or identification number | 028483 | | Number of Individuals Covered | 158 | | Insurance policy start date | 2012-02-01 | | Insurance policy end date | 2013-01-31 | | Total amount of commissions paid to insurance broker | USD $17,692 | | 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 | | Other welfare benefits provided | ABCBS HSA | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| SUN LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80926 ) |
| Policy contract number | 057-6717-00 |
| Policy instance | 4 |
| Insurance contract or identification number | 057-6717-00 | | Number of Individuals Covered | 83 | | Insurance policy start date | 2012-02-01 | | Insurance policy end date | 2013-02-01 | | Total amount of commissions paid to insurance broker | USD $4,346 | | 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 | | Temporary Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | VOL LIFE VOL DEP LIFE | | Welfare Benefit Premiums Paid to Carrier | USD $31,351 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,346 | | Insurance broker organization code? | 3 | | Insurance broker name | GALLAGHER BENEFIT SERVICES INC |
|
| SUN LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80926 ) |
| Policy contract number | 057-6717-00 |
| Policy instance | 2 |
| Insurance contract or identification number | 057-6717-00 | | Number of Individuals Covered | 83 | | Insurance policy start date | 2012-02-01 | | Insurance policy end date | 2013-02-01 | | Total amount of commissions paid to insurance broker | USD $4,346 | | 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 | | Temporary Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | VOL LIFE VOL DEP LIFE | | Welfare Benefit Premiums Paid to Carrier | USD $31,351 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 00470562 |
| Policy instance | 2 |
| Insurance contract or identification number | 00470562 | | Number of Individuals Covered | 56 | | Insurance policy start date | 2012-02-01 | | Insurance policy end date | 2013-01-31 | | Total amount of commissions paid to insurance broker | USD $1,052 | | Total amount of fees paid to insurance company | USD $213 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Vision 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 $1,026 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 213 | | Insurance broker name | CHARTWELL FINANCIAL GROUP LLC |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 00470562 |
| Policy instance | 4 |
| Insurance contract or identification number | 00470562 | | Number of Individuals Covered | 56 | | Insurance policy start date | 2012-02-01 | | Insurance policy end date | 2013-01-31 | | Total amount of commissions paid to insurance broker | USD $1,052 | | Total amount of fees paid to insurance company | USD $213 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Vision Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| ARKANSAS BLUE CROSS BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 83470 ) |
| Policy contract number | 028483 |
| Policy instance | 4 |
| Insurance contract or identification number | 028483 | | Number of Individuals Covered | 232 | | Insurance policy start date | 2011-09-01 | | Insurance policy end date | 2012-01-31 | | Total amount of commissions paid to insurance broker | USD $12,844 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ABCBS HSA | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
| Policy contract number | 00470562 |
| Policy instance | 3 |
| Insurance contract or identification number | 00470562 | | Number of Individuals Covered | 47 | | Insurance policy start date | 2011-09-01 | | Insurance policy end date | 2012-01-31 | | Total amount of commissions paid to insurance broker | USD $394 | | 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 AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80926 ) |
| Policy contract number | 057-6717-00 |
| Policy instance | 2 |
| Insurance contract or identification number | 057-6717-00 | | Number of Individuals Covered | 80 | | Insurance policy start date | 2011-02-01 | | Insurance policy end date | 2012-01-31 | | Total amount of commissions paid to insurance broker | USD $4,100 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | VOL LIFE VOL DEP LIFE | | Welfare Benefit Premiums Paid to Carrier | USD $29,712 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| DELTA DENTAL PLAN OF ARKANSAS (National Association of Insurance Commissioners NAIC id number: 47155 ) |
| Policy contract number | 000005608 |
| Policy instance | 1 |
| Insurance contract or identification number | 000005608 | | Number of Individuals Covered | 248 | | Insurance policy start date | 2011-02-01 | | Insurance policy end date | 2012-01-31 | | Total amount of commissions paid to insurance broker | USD $2,825 | | 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 |
|
| ARKANSAS BLUE CROSS BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 83470 ) |
| Policy contract number | 028483 |
| Policy instance | 3 |
| Insurance contract or identification number | 028483 | | Number of Individuals Covered | 245 | | Insurance policy start date | 2010-09-01 | | Insurance policy end date | 2011-01-31 | | Total amount of commissions paid to insurance broker | USD $11,345 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ABCBS HSA | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| SUN LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80926 ) |
| Policy contract number | 057-6717-00 |
| Policy instance | 2 |
| Insurance contract or identification number | 057-6717-00 | | Number of Individuals Covered | 78 | | Insurance policy start date | 2010-02-01 | | Insurance policy end date | 2011-01-31 | | Total amount of commissions paid to insurance broker | USD $4,191 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | VOL LIFE VOL DEP LIFE | | Welfare Benefit Premiums Paid to Carrier | USD $32,700 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| DELTA DENTAL PLAN OF ARKANSAS (National Association of Insurance Commissioners NAIC id number: 47155 ) |
| Policy contract number | 000005608 |
| Policy instance | 1 |
| Insurance contract or identification number | 000005608 | | Number of Individuals Covered | 253 | | Insurance policy start date | 2010-02-01 | | Insurance policy end date | 2011-01-31 | | Total amount of commissions paid to insurance broker | USD $2,834 | | 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 |
|
