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PRESTIGE CLEANERS, INC. 401k Plan overview

Plan NamePRESTIGE CLEANERS, INC.
Plan identification number 501

PRESTIGE CLEANERS, INC. Benefits

401k Plan TypeWelfare Benefit
Plan Features/Benefits
  • Health (other than dental or vision)
  • Life insurance
  • Dental
  • Vision
  • Temporary disability (accident and sickness)
  • Other welfare benefit cover
  • Unfunded, fully insured, or combination unfunded/insured welfare plan that will not file a Form 5500 for next plan year pursuant to 29 CFR 2520.104-20.

401k Sponsoring company profile

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

Company Name:PRESTIGE CLEANERS, INC.
Employer identification number (EIN):621412007
NAIC Classification:812320
NAIC Description:Drycleaning and Laundry Services (except Coin-Operated)

Additional information about PRESTIGE CLEANERS, INC.

Jurisdiction of Incorporation: Colorado Department of State
Incorporation Date: 2002-02-19
Company Identification Number: 20021039283
Legal Registered Office Address: 936 CHAMBERS COURT #A4

Eagle
United States of America (USA)
81631

More information about PRESTIGE CLEANERS, INC.

Form 5500 Filing Information

Submission information for form 5500 for 401k plan PRESTIGE CLEANERS, INC.

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5012021-08-01
5012020-08-01
5012019-08-01
5012019-01-01
5012018-01-01
5012017-01-01MICHAEL SCOTT HOPSON
5012016-01-01JANICE LYNN RECTOR
5012015-01-01JAN RECTOR
5012014-01-01JAN RECTOR
5012013-01-01JAN RECTOR
5012012-01-01JAN RECTOR
5012011-01-01JAN RECTOR
5012010-12-01JAN RECTOR
5012009-12-01JAN RECTOR
5012008-12-01JAN RECTOR
5012007-12-01JAN RECTOR
5012006-12-01JAN RECTOR

Plan Statistics for PRESTIGE CLEANERS, INC.

401k plan membership statisitcs for PRESTIGE CLEANERS, INC.

Measure Date Value
2021: PRESTIGE CLEANERS, INC. 2021 401k membership
Total participants, beginning-of-year2021-08-0187
Total number of active participants reported on line 7a of the Form 55002021-08-0174
Number of retired or separated participants receiving benefits2021-08-011
Number of other retired or separated participants entitled to future benefits2021-08-011
Total of all active and inactive participants2021-08-0176
2020: PRESTIGE CLEANERS, INC. 2020 401k membership
Total participants, beginning-of-year2020-08-0184
Total number of active participants reported on line 7a of the Form 55002020-08-0171
Number of retired or separated participants receiving benefits2020-08-011
Number of other retired or separated participants entitled to future benefits2020-08-010
Total of all active and inactive participants2020-08-0172
2019: PRESTIGE CLEANERS, INC. 2019 401k membership
Total participants, beginning-of-year2019-08-01103
Total number of active participants reported on line 7a of the Form 55002019-08-0184
Number of retired or separated participants receiving benefits2019-08-013
Number of other retired or separated participants entitled to future benefits2019-08-013
Total of all active and inactive participants2019-08-0190
Total participants, beginning-of-year2019-01-01112
Total number of active participants reported on line 7a of the Form 55002019-01-01113
Number of retired or separated participants receiving benefits2019-01-010
Number of other retired or separated participants entitled to future benefits2019-01-011
Total of all active and inactive participants2019-01-01114
2018: PRESTIGE CLEANERS, INC. 2018 401k membership
Total participants, beginning-of-year2018-01-01110
Total number of active participants reported on line 7a of the Form 55002018-01-01107
Number of retired or separated participants receiving benefits2018-01-010
Number of other retired or separated participants entitled to future benefits2018-01-010
Total of all active and inactive participants2018-01-01107
2017: PRESTIGE CLEANERS, INC. 2017 401k membership
Total participants, beginning-of-year2017-01-01115
Total number of active participants reported on line 7a of the Form 55002017-01-01106
Number of retired or separated participants receiving benefits2017-01-010
Number of other retired or separated participants entitled to future benefits2017-01-010
Total of all active and inactive participants2017-01-01106
2016: PRESTIGE CLEANERS, INC. 2016 401k membership
Total participants, beginning-of-year2016-01-01114
Total number of active participants reported on line 7a of the Form 55002016-01-01109
Number of retired or separated participants receiving benefits2016-01-010
Number of other retired or separated participants entitled to future benefits2016-01-010
Total of all active and inactive participants2016-01-01109
2015: PRESTIGE CLEANERS, INC. 2015 401k membership
Total participants, beginning-of-year2015-01-01116
Total number of active participants reported on line 7a of the Form 55002015-01-01109
Total of all active and inactive participants2015-01-01109
2014: PRESTIGE CLEANERS, INC. 2014 401k membership
Total participants, beginning-of-year2014-01-01113
Total number of active participants reported on line 7a of the Form 55002014-01-01116
Total of all active and inactive participants2014-01-01116
2013: PRESTIGE CLEANERS, INC. 2013 401k membership
Total participants, beginning-of-year2013-01-01122
Total number of active participants reported on line 7a of the Form 55002013-01-01113
Total of all active and inactive participants2013-01-01113
2012: PRESTIGE CLEANERS, INC. 2012 401k membership
Total participants, beginning-of-year2012-01-01112
Total number of active participants reported on line 7a of the Form 55002012-01-01122
Total of all active and inactive participants2012-01-01122
2011: PRESTIGE CLEANERS, INC. 2011 401k membership
Total participants, beginning-of-year2011-01-01106
Total number of active participants reported on line 7a of the Form 55002011-01-01112
Total of all active and inactive participants2011-01-01112
2010: PRESTIGE CLEANERS, INC. 2010 401k membership
Total participants, beginning-of-year2010-12-01100
Total number of active participants reported on line 7a of the Form 55002010-12-01106
Total of all active and inactive participants2010-12-01106
2009: PRESTIGE CLEANERS, INC. 2009 401k membership
Total participants, beginning-of-year2009-12-01120
Total number of active participants reported on line 7a of the Form 55002009-12-01100
Total of all active and inactive participants2009-12-01100
2008: PRESTIGE CLEANERS, INC. 2008 401k membership
Total participants, beginning-of-year2008-12-01116
Total number of active participants reported on line 7a of the Form 55002008-12-01120
Total of all active and inactive participants2008-12-01120
2007: PRESTIGE CLEANERS, INC. 2007 401k membership
Total participants, beginning-of-year2007-12-01111
Total number of active participants reported on line 7a of the Form 55002007-12-01116
Total of all active and inactive participants2007-12-01116
2006: PRESTIGE CLEANERS, INC. 2006 401k membership
Total participants, beginning-of-year2006-12-0198
Total number of active participants reported on line 7a of the Form 55002006-12-01111
Total of all active and inactive participants2006-12-01111

Form 5500 Responses for PRESTIGE CLEANERS, INC.

2021: PRESTIGE CLEANERS, INC. 2021 form 5500 responses
2021-08-01Type of plan entitySingle employer plan
2021-08-01Submission has been amendedNo
2021-08-01This submission is the final filingNo
2021-08-01This return/report is a short plan year return/report (less than 12 months)No
2021-08-01Plan is a collectively bargained planNo
2021-08-01Plan funding arrangement – InsuranceYes
2021-08-01Plan benefit arrangement – InsuranceYes
2020: PRESTIGE CLEANERS, INC. 2020 form 5500 responses
2020-08-01Type of plan entitySingle employer plan
2020-08-01Submission has been amendedNo
2020-08-01This submission is the final filingNo
2020-08-01This return/report is a short plan year return/report (less than 12 months)No
2020-08-01Plan is a collectively bargained planNo
2020-08-01Plan funding arrangement – InsuranceYes
2020-08-01Plan benefit arrangement – InsuranceYes
2019: PRESTIGE CLEANERS, INC. 2019 form 5500 responses
2019-08-01Type of plan entitySingle employer plan
2019-08-01Submission has been amendedNo
2019-08-01This submission is the final filingNo
2019-08-01This return/report is a short plan year return/report (less than 12 months)No
2019-08-01Plan is a collectively bargained planNo
2019-08-01Plan funding arrangement – InsuranceYes
2019-08-01Plan benefit arrangement – InsuranceYes
2019-01-01Type of plan entitySingle employer plan
2019-01-01Submission has been amendedNo
2019-01-01This submission is the final filingNo
2019-01-01This return/report is a short plan year return/report (less than 12 months)Yes
2019-01-01Plan is a collectively bargained planNo
2019-01-01Plan funding arrangement – InsuranceYes
2019-01-01Plan benefit arrangement – InsuranceYes
2018: PRESTIGE CLEANERS, INC. 2018 form 5500 responses
2018-01-01Type of plan entitySingle employer plan
2018-01-01Submission has been amendedNo
2018-01-01This submission is the final filingNo
2018-01-01This return/report is a short plan year return/report (less than 12 months)No
2018-01-01Plan is a collectively bargained planNo
2018-01-01Plan funding arrangement – InsuranceYes
2018-01-01Plan benefit arrangement – InsuranceYes
2017: PRESTIGE CLEANERS, INC. 2017 form 5500 responses
2017-01-01Type of plan entitySingle employer plan
2017-01-01Submission has been amendedNo
2017-01-01This submission is the final filingNo
2017-01-01This return/report is a short plan year return/report (less than 12 months)No
2017-01-01Plan is a collectively bargained planNo
2017-01-01Plan funding arrangement – InsuranceYes
2017-01-01Plan benefit arrangement – InsuranceYes
2016: PRESTIGE CLEANERS, INC. 2016 form 5500 responses
2016-01-01Type of plan entitySingle employer plan
2016-01-01Submission has been amendedNo
2016-01-01This submission is the final filingNo
2016-01-01This return/report is a short plan year return/report (less than 12 months)No
2016-01-01Plan is a collectively bargained planNo
2016-01-01Plan funding arrangement – InsuranceYes
2016-01-01Plan benefit arrangement – InsuranceYes
2015: PRESTIGE CLEANERS, INC. 2015 form 5500 responses
2015-01-01Type of plan entitySingle employer plan
2015-01-01Plan funding arrangement – InsuranceYes
2015-01-01Plan benefit arrangement – InsuranceYes
2014: PRESTIGE CLEANERS, INC. 2014 form 5500 responses
2014-01-01Type of plan entitySingle employer plan
2014-01-01Plan funding arrangement – InsuranceYes
2014-01-01Plan benefit arrangement – InsuranceYes
2013: PRESTIGE CLEANERS, INC. 2013 form 5500 responses
2013-01-01Type of plan entitySingle employer plan
2013-01-01Plan funding arrangement – InsuranceYes
2013-01-01Plan benefit arrangement – InsuranceYes
2012: PRESTIGE CLEANERS, INC. 2012 form 5500 responses
2012-01-01Type of plan entitySingle employer plan
2012-01-01Plan funding arrangement – InsuranceYes
2012-01-01Plan benefit arrangement – InsuranceYes
2011: PRESTIGE CLEANERS, INC. 2011 form 5500 responses
2011-01-01Type of plan entitySingle employer plan
2011-01-01Plan funding arrangement – InsuranceYes
2011-01-01Plan benefit arrangement – InsuranceYes
2010: PRESTIGE CLEANERS, INC. 2010 form 5500 responses
2010-12-01Type of plan entitySingle employer plan
2010-12-01This return/report is a short plan year return/report (less than 12 months)Yes
2010-12-01Plan funding arrangement – InsuranceYes
2010-12-01Plan benefit arrangement – InsuranceYes
2009: PRESTIGE CLEANERS, INC. 2009 form 5500 responses
2009-12-01Type of plan entitySingle employer plan
2009-12-01This submission is the final filingNo
2009-12-01Plan funding arrangement – InsuranceYes
2009-12-01Plan benefit arrangement – InsuranceYes
2008: PRESTIGE CLEANERS, INC. 2008 form 5500 responses
2008-12-01Type of plan entitySingle employer plan
2008-12-01This submission is the final filingNo
2008-12-01Plan funding arrangement – InsuranceYes
2008-12-01Plan benefit arrangement – InsuranceYes
2007: PRESTIGE CLEANERS, INC. 2007 form 5500 responses
2007-12-01Type of plan entitySingle employer plan
2007-12-01This submission is the final filingNo
2007-12-01Plan funding arrangement – InsuranceYes
2007-12-01Plan benefit arrangement – InsuranceYes
2006: PRESTIGE CLEANERS, INC. 2006 form 5500 responses
2006-12-01Type of plan entitySingle employer plan
2006-12-01This submission is the final filingNo
2006-12-01Plan funding arrangement – InsuranceYes
2006-12-01Plan benefit arrangement – InsuranceYes

Insurance Providers Used on plan

USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )
Policy contract number50026833
Policy instance 3
Insurance contract or identification number50026833
Number of Individuals Covered69
Insurance policy start date2021-08-01
Insurance policy end date2022-07-31
Total amount of commissions paid to insurance brokerUSD $842
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&D
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $2,968
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $445
Insurance broker organization code?3
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number05L7431
Policy instance 2
Insurance contract or identification number05L7431
Number of Individuals Covered37
Insurance policy start date2021-08-01
Insurance policy end date2022-07-31
Total amount of commissions paid to insurance brokerUSD $10,898
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $272,233
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $10,898
Insurance broker organization code?3
BLUECROSS BLUESHIELD OF TENNESSEE, INC. (National Association of Insurance Commissioners NAIC id number: 54518 )
Policy contract number133553
Policy instance 1
Insurance contract or identification number133553
Number of Individuals Covered51
Insurance policy start date2021-08-01
Insurance policy end date2022-07-31
Total amount of commissions paid to insurance brokerUSD $2,192
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $22,367
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,192
Insurance broker organization code?3
USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )
Policy contract number50026833
Policy instance 3
Insurance contract or identification number50026833
Number of Individuals Covered72
Insurance policy start date2020-08-01
Insurance policy end date2021-07-31
Total amount of commissions paid to insurance brokerUSD $874
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&D
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $3,215
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $482
Insurance broker organization code?3
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number05L7431
Policy instance 2
Insurance contract or identification number05L7431
Number of Individuals Covered46
Insurance policy start date2020-08-01
Insurance policy end date2021-07-31
Total amount of commissions paid to insurance brokerUSD $14,081
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $351,767
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $14,081
Insurance broker organization code?3
BLUECROSS BLUESHIELD OF TENNESSEE, INC. (National Association of Insurance Commissioners NAIC id number: 54518 )
Policy contract number133553
Policy instance 1
Insurance contract or identification number133553
Number of Individuals Covered55
Insurance policy start date2020-08-01
Insurance policy end date2021-07-31
Total amount of commissions paid to insurance brokerUSD $2,485
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $24,230
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,485
Insurance broker organization code?3
BLUECROSS BLUESHIELD OF TENNESSEE, INC. (National Association of Insurance Commissioners NAIC id number: 54518 )
Policy contract number133553
Policy instance 1
Insurance contract or identification number133553
Number of Individuals Covered81
Insurance policy start date2019-08-01
Insurance policy end date2020-07-31
Total amount of commissions paid to insurance brokerUSD $3,242
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $36,092
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,242
Insurance broker organization code?3
HUMANA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 73288 )
Policy contract number553269
Policy instance 2
Insurance contract or identification number553269
Number of Individuals Covered50
Insurance policy start date2019-08-01
Insurance policy end date2020-07-31
Total amount of commissions paid to insurance brokerUSD $18,648
Total amount of fees paid to insurance companyUSD $1,391
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $399,924
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $18,648
Amount paid for insurance broker fees1391
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )
Policy contract number50026833
Policy instance 3
Insurance contract or identification number50026833
Number of Individuals Covered84
Insurance policy start date2019-08-01
Insurance policy end date2020-07-31
Total amount of commissions paid to insurance brokerUSD $1,194
Total amount of fees paid to insurance companyUSD $45
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&D
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $4,534
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $680
Amount paid for insurance broker fees45
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )
Policy contract number50026833
Policy instance 4
Insurance contract or identification number50026833
Number of Individuals Covered39
Insurance policy start date2019-08-01
Insurance policy end date2020-07-31
Total amount of commissions paid to insurance brokerUSD $446
Total amount of fees paid to insurance companyUSD $16
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedSUPPLEMENTAL AD&D, DEPENDENT AD&D
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $1,590
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $239
Amount paid for insurance broker fees16
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )
Policy contract number50026833
Policy instance 5
Insurance contract or identification number50026833
Number of Individuals Covered44
Insurance policy start date2019-08-01
Insurance policy end date2020-07-31
Total amount of commissions paid to insurance brokerUSD $3,413
Total amount of fees paid to insurance companyUSD $115
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedSUPPLEMENTAL LIFE, DEPENDENT LIFE
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $12,188
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,828
Amount paid for insurance broker fees115
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )
Policy contract number50026833
Policy instance 6
Insurance contract or identification number50026833
Number of Individuals Covered9
Insurance policy start date2019-08-01
Insurance policy end date2020-07-31
Total amount of commissions paid to insurance brokerUSD $860
Total amount of fees paid to insurance companyUSD $32
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $3,070
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $461
Amount paid for insurance broker fees32
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )
Policy contract number50026833
Policy instance 6
Insurance contract or identification number50026833
Number of Individuals Covered11
Insurance policy start date2019-01-01
Insurance policy end date2019-07-31
Total amount of commissions paid to insurance brokerUSD $526
Total amount of fees paid to insurance companyUSD $35
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $1,881
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $282
Amount paid for insurance broker fees35
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )
Policy contract number50026833
Policy instance 5
Insurance contract or identification number50026833
Number of Individuals Covered49
Insurance policy start date2019-01-01
Insurance policy end date2019-07-31
Total amount of commissions paid to insurance brokerUSD $1,873
Total amount of fees paid to insurance companyUSD $119
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedSUPPLEMENTAL LIFE, DEPENDENT LIFE
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $6,690
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,003
Amount paid for insurance broker fees119
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )
Policy contract number50026833
Policy instance 4
Insurance contract or identification number50026833
Number of Individuals Covered41
Insurance policy start date2019-01-01
Insurance policy end date2019-07-31
Total amount of commissions paid to insurance brokerUSD $246
Total amount of fees paid to insurance companyUSD $16
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedSUPPLEMENTAL AD&D, DEPENDENT AD&D
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $877
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $132
Amount paid for insurance broker fees16
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )
Policy contract number50026833
Policy instance 3
Insurance contract or identification number50026833
Number of Individuals Covered105
Insurance policy start date2019-01-01
Insurance policy end date2019-07-31
Total amount of commissions paid to insurance brokerUSD $760
Total amount of fees paid to insurance companyUSD $44
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&D
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $2,618
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $393
Amount paid for insurance broker fees44
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
HUMANA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 73288 )
Policy contract number553269
Policy instance 2
Insurance contract or identification number553269
Number of Individuals Covered60
Insurance policy start date2019-01-01
Insurance policy end date2019-07-31
Total amount of commissions paid to insurance brokerUSD $7,224
Total amount of fees paid to insurance companyUSD $664
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $242,816
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $7,224
Amount paid for insurance broker fees664
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
BLUECROSS BLUESHIELD OF TENNESSEE, INC. (National Association of Insurance Commissioners NAIC id number: 54518 )
Policy contract number133553
Policy instance 1
Insurance contract or identification number133553
Number of Individuals Covered103
Insurance policy start date2019-01-01
Insurance policy end date2019-07-31
Total amount of commissions paid to insurance brokerUSD $2,265
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $22,937
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,265
Insurance broker organization code?3
USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )
Policy contract number50026833
Policy instance 6
Insurance contract or identification number50026833
Number of Individuals Covered12
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $1,070
Total amount of fees paid to insurance companyUSD $206
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedSHORT-TERM DISABILITY CLASS 2
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $3,821
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $573
Amount paid for insurance broker fees206
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )
Policy contract number50026833
Policy instance 5
Insurance contract or identification number50026833
Number of Individuals Covered57
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $3,273
Total amount of fees paid to insurance companyUSD $494
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedSUPPLEMENTAL LIFE, DEPENDENT LIFE
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $11,690
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,753
Amount paid for insurance broker fees494
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )
Policy contract number50026833
Policy instance 4
Insurance contract or identification number50026833
Number of Individuals Covered39
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $428
Total amount of fees paid to insurance companyUSD $81
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedSUPPLEMENTAL AD&D, DEPENDENT AD&D
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $1,529
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $229
Amount paid for insurance broker fees81
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )
Policy contract number50026833
Policy instance 3
Insurance contract or identification number50026833
Number of Individuals Covered108
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $1,087
Total amount of fees paid to insurance companyUSD $166
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&D
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $4,123
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $618
Amount paid for insurance broker fees166
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
HUMANA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 73288 )
Policy contract number553269
Policy instance 2
Insurance contract or identification number553269
Number of Individuals Covered67
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $16,474
Total amount of fees paid to insurance companyUSD $1,080
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $344,108
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $16,474
Amount paid for insurance broker fees1080
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
BLUECROSS BLUESHIELD OF TENNESSEE, INC. (National Association of Insurance Commissioners NAIC id number: 54518 )
Policy contract number133553
Policy instance 1
Insurance contract or identification number133553
Number of Individuals Covered107
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $3,748
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $38,750
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,748
Insurance broker organization code?3
BLUECROSS BLUESHIELD OF TENNESSEE, INC. (National Association of Insurance Commissioners NAIC id number: 54518 )
Policy contract number133553
Policy instance 1
Insurance contract or identification number133553
Number of Individuals Covered107
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $2,884
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $40,657
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,884
Insurance broker organization code?3
Insurance broker nameLISA ROBINETTE
HUMANA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 73288 )
Policy contract number553269
Policy instance 2
Insurance contract or identification number553269
Number of Individuals Covered53
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $14,432
Total amount of fees paid to insurance companyUSD $1,124
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $270,685
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $14,432
Amount paid for insurance broker fees1124
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
Insurance broker nameSHAFER INSURANCE AGENCY INC
USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )
Policy contract number50026833
Policy instance 3
Insurance contract or identification number50026833
Number of Individuals Covered105
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $755
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedAD&D
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $3,352
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $503
Insurance broker organization code?3
Insurance broker nameSHAFER INSURANCE AGENCY INC
USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )
Policy contract number50026833
Policy instance 4
Insurance contract or identification number50026833
Number of Individuals Covered15
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $1,118
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedSHORT-TERM DISABILITY CLASS 2
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $3,993
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $519
Insurance broker organization code?3
Insurance broker nameGROUP INSURANCE SERVICES INC
USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )
Policy contract number50026833
Policy instance 5
Insurance contract or identification number50026833
Number of Individuals Covered66
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $2,750
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedSUPPLEMENTAL LIFE, DEPENDENT LIFE
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $9,823
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,473
Insurance broker organization code?3
Insurance broker nameGROUP INSURANCE SERVICES INC
USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )
Policy contract number50026833
Policy instance 6
Insurance contract or identification number50026833
Number of Individuals Covered45
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $428
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedSUPPLEMENTAL AD&D, DEPENDENT AD&D
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $1,527
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $229
Insurance broker organization code?3
Insurance broker nameGROUP INSURANCE SERVICES INC
USABLE LIFE (National Association of Insurance Commissioners NAIC id number: 94358 )
Policy contract number50026833
Policy instance 7
Insurance contract or identification number50026833
Number of Individuals Covered31
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $1,474
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?0
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?No
Are there contracts with unallocated funds for contracts of type guaranteed investment?No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?No
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Welfare Benefit Premiums Paid to CarrierUSD $6,519
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $978
Insurance broker organization code?3
Insurance broker nameGROUP INSURANCE SERVICES INC
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number00464572
Policy instance 1
Insurance contract or identification number00464572
Number of Individuals Covered109
Insurance policy start date2015-01-01
Insurance policy end date2015-12-31
Total amount of commissions paid to insurance brokerUSD $610
Total amount of fees paid to insurance companyUSD $268
Life Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $4,069
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $610
Amount paid for insurance broker fees268
Insurance broker organization code?3
Insurance broker nameTRINITY BENEFIT ADVISORS
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number00464572
Policy instance 1
Insurance contract or identification number00464572
Number of Individuals Covered116
Insurance policy start date2014-01-01
Insurance policy end date2014-12-31
Total amount of commissions paid to insurance brokerUSD $677
Total amount of fees paid to insurance companyUSD $174
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Life Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $4,513
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $677
Amount paid for insurance broker fees174
Insurance broker organization code?3
Insurance broker nameTRINITY BENEFIT ADVISORS
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number00464572
Policy instance 1
Insurance contract or identification number00464572
Number of Individuals Covered113
Insurance policy start date2013-01-01
Insurance policy end date2013-12-31
Total amount of commissions paid to insurance brokerUSD $614
Total amount of fees paid to insurance companyUSD $160
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Life Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $4,091
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $614
Amount paid for insurance broker fees160
Insurance broker organization code?3
Insurance broker nameTRINITY BENEFIT ADVISORS
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number00464572
Policy instance 1
Insurance contract or identification number00464572
Number of Individuals Covered122
Insurance policy start date2012-01-01
Insurance policy end date2012-12-31
Total amount of commissions paid to insurance brokerUSD $566
Total amount of fees paid to insurance companyUSD $172
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Life Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $3,771
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $566
Amount paid for insurance broker fees172
Insurance broker organization code?3
Insurance broker nameTRINITY BENEFIT ADVISORS
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number00464572
Policy instance 1
Insurance contract or identification number00464572
Number of Individuals Covered112
Insurance policy start date2011-01-01
Insurance policy end date2011-12-31
Total amount of commissions paid to insurance brokerUSD $607
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Life Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $4,043
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 )
Policy contract numberFT81454
Policy instance 1
Insurance contract or identification numberFT81454
Number of Individuals Covered106
Insurance policy start date2010-12-01
Insurance policy end date2010-12-31
Total amount of commissions paid to insurance brokerUSD $57
Total amount of fees paid to insurance companyUSD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Life Insurance Welfare BenefitYes
Other welfare benefits providedAD&D
Welfare Benefit Premiums Paid to CarrierUSD $380
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No

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