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BANK INDEPENDENT LTD 401k Plan overview

Plan NameBANK INDEPENDENT LTD
Plan identification number 505

BANK INDEPENDENT LTD Benefits

401k Plan TypeWelfare Benefit
Plan Features/Benefits
  • Long-term disability cover

401k Sponsoring company profile

BANK INDEPENDENT has sponsored the creation of one or more 401k plans.

Company Name:BANK INDEPENDENT
Employer identification number (EIN):630260591
NAIC Classification:522110
NAIC Description:Commercial Banking

Additional information about BANK INDEPENDENT

Jurisdiction of Incorporation: Alabama Secretary of State
Incorporation Date: 1982-12-01
Company Identification Number: 089-663
Legal Registered Office Address: 304 EAST DR HICKS BLVD FLORENCE,


United States of America (USA)
35630

More information about BANK INDEPENDENT

Form 5500 Filing Information

Submission information for form 5500 for 401k plan BANK INDEPENDENT LTD

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5052012-01-01CAROL UNDERWOOD CAROL UNDERWOOD2016-11-09
5052011-01-01CAROL UNDERWOOD CAROL UNDERWOOD2016-11-09
5052010-01-01CAROL UNDERWOOD CAROL UNDERWOOD2016-11-09
5052009-01-01CAROL UNDERWOOD CAROL UNDERWOOD2016-11-09
5052008-01-01CAROL UNDERWOOD CAROL UNDERWOOD2016-11-09
5052007-01-01CAROL UNDERWOOD CAROL UNDERWOOD2016-11-09
5052006-01-01CAROL UNDERWOOD CAROL UNDERWOOD2016-11-09
5052005-01-01CAROL UNDERWOOD CAROL UNDERWOOD2016-11-09
5052004-01-01CAROL UNDERWOOD CAROL UNDERWOOD2016-11-09
5052003-01-01CAROL UNDERWOOD CAROL UNDERWOOD2016-11-09
5052002-01-01CAROL UNDERWOOD CAROL UNDERWOOD2016-11-09

Plan Statistics for BANK INDEPENDENT LTD

401k plan membership statisitcs for BANK INDEPENDENT LTD

Measure Date Value
2012: BANK INDEPENDENT LTD 2012 401k membership
Total participants, beginning-of-year2012-01-01387
Total number of active participants reported on line 7a of the Form 55002012-01-01402
Total of all active and inactive participants2012-01-01402
Total participants2012-01-01402
2011: BANK INDEPENDENT LTD 2011 401k membership
Total participants, beginning-of-year2011-01-01346
Total number of active participants reported on line 7a of the Form 55002011-01-01387
Total of all active and inactive participants2011-01-01387
Total participants2011-01-01387
2010: BANK INDEPENDENT LTD 2010 401k membership
Total participants, beginning-of-year2010-01-01281
Total number of active participants reported on line 7a of the Form 55002010-01-01346
Total of all active and inactive participants2010-01-01346
Total participants2010-01-01346
2009: BANK INDEPENDENT LTD 2009 401k membership
Total participants, beginning-of-year2009-01-01236
Total number of active participants reported on line 7a of the Form 55002009-01-01281
Total of all active and inactive participants2009-01-01281
Total participants2009-01-01281
2008: BANK INDEPENDENT LTD 2008 401k membership
Total participants, beginning-of-year2008-01-01220
Total number of active participants reported on line 7a of the Form 55002008-01-01236
Total of all active and inactive participants2008-01-01236
Total participants2008-01-01236
2007: BANK INDEPENDENT LTD 2007 401k membership
Total participants, beginning-of-year2007-01-01209
Total number of active participants reported on line 7a of the Form 55002007-01-01220
Total of all active and inactive participants2007-01-01220
Total participants2007-01-01220
2006: BANK INDEPENDENT LTD 2006 401k membership
Total participants, beginning-of-year2006-01-01121
Total number of active participants reported on line 7a of the Form 55002006-01-01209
Total of all active and inactive participants2006-01-01209
Total participants2006-01-01209
2005: BANK INDEPENDENT LTD 2005 401k membership
Total participants, beginning-of-year2005-01-01122
Total number of active participants reported on line 7a of the Form 55002005-01-01121
Total of all active and inactive participants2005-01-01121
Total participants2005-01-01121
2004: BANK INDEPENDENT LTD 2004 401k membership
Total participants, beginning-of-year2004-01-01123
Total number of active participants reported on line 7a of the Form 55002004-01-01122
Total of all active and inactive participants2004-01-01122
Total participants2004-01-01122
2003: BANK INDEPENDENT LTD 2003 401k membership
Total participants, beginning-of-year2003-01-01111
Total number of active participants reported on line 7a of the Form 55002003-01-01123
Total of all active and inactive participants2003-01-01123
Total participants2003-01-01123
2002: BANK INDEPENDENT LTD 2002 401k membership
Total participants, beginning-of-year2002-01-01111
Total number of active participants reported on line 7a of the Form 55002002-01-01111
Total of all active and inactive participants2002-01-01111
Total participants2002-01-01111

Form 5500 Responses for BANK INDEPENDENT LTD

2012: BANK INDEPENDENT LTD 2012 form 5500 responses
2012-01-01Type of plan entitySingle employer plan
2012-01-01Submission has been amendedNo
2012-01-01This submission is the final filingNo
2012-01-01This return/report is a short plan year return/report (less than 12 months)Yes
2012-01-01Plan is a collectively bargained planNo
2012-01-01Plan funding arrangement – InsuranceYes
2012-01-01Plan benefit arrangement – InsuranceYes
2011: BANK INDEPENDENT LTD 2011 form 5500 responses
2011-01-01Type of plan entitySingle employer plan
2011-01-01Submission has been amendedNo
2011-01-01This submission is the final filingNo
2011-01-01This return/report is a short plan year return/report (less than 12 months)No
2011-01-01Plan is a collectively bargained planNo
2011-01-01Plan funding arrangement – InsuranceYes
2011-01-01Plan benefit arrangement – InsuranceYes
2010: BANK INDEPENDENT LTD 2010 form 5500 responses
2010-01-01Type of plan entitySingle employer plan
2010-01-01Submission has been amendedNo
2010-01-01This submission is the final filingNo
2010-01-01This return/report is a short plan year return/report (less than 12 months)No
2010-01-01Plan is a collectively bargained planNo
2010-01-01Plan funding arrangement – InsuranceYes
2010-01-01Plan benefit arrangement – InsuranceYes
2009: BANK INDEPENDENT LTD 2009 form 5500 responses
2009-01-01Type of plan entitySingle employer plan
2009-01-01Submission has been amendedNo
2009-01-01This submission is the final filingNo
2009-01-01This return/report is a short plan year return/report (less than 12 months)No
2009-01-01Plan is a collectively bargained planNo
2009-01-01Plan funding arrangement – InsuranceYes
2009-01-01Plan benefit arrangement – InsuranceYes
2008: BANK INDEPENDENT LTD 2008 form 5500 responses
2008-01-01Type of plan entitySingle employer plan
2008-01-01Submission has been amendedNo
2008-01-01This submission is the final filingNo
2008-01-01This return/report is a short plan year return/report (less than 12 months)No
2008-01-01Plan is a collectively bargained planNo
2008-01-01Plan funding arrangement – InsuranceYes
2008-01-01Plan benefit arrangement – InsuranceYes
2007: BANK INDEPENDENT LTD 2007 form 5500 responses
2007-01-01Type of plan entitySingle employer plan
2007-01-01Submission has been amendedNo
2007-01-01This submission is the final filingNo
2007-01-01This return/report is a short plan year return/report (less than 12 months)No
2007-01-01Plan is a collectively bargained planNo
2007-01-01Plan funding arrangement – InsuranceYes
2007-01-01Plan benefit arrangement – InsuranceYes
2006: BANK INDEPENDENT LTD 2006 form 5500 responses
2006-01-01Type of plan entitySingle employer plan
2006-01-01Submission has been amendedNo
2006-01-01This submission is the final filingNo
2006-01-01This return/report is a short plan year return/report (less than 12 months)No
2006-01-01Plan is a collectively bargained planNo
2006-01-01Plan funding arrangement – InsuranceYes
2006-01-01Plan benefit arrangement – InsuranceYes
2005: BANK INDEPENDENT LTD 2005 form 5500 responses
2005-01-01Type of plan entitySingle employer plan
2005-01-01Submission has been amendedNo
2005-01-01This submission is the final filingNo
2005-01-01This return/report is a short plan year return/report (less than 12 months)No
2005-01-01Plan is a collectively bargained planNo
2005-01-01Plan funding arrangement – InsuranceYes
2005-01-01Plan benefit arrangement – InsuranceYes
2004: BANK INDEPENDENT LTD 2004 form 5500 responses
2004-01-01Type of plan entitySingle employer plan
2004-01-01Submission has been amendedNo
2004-01-01This submission is the final filingNo
2004-01-01This return/report is a short plan year return/report (less than 12 months)No
2004-01-01Plan is a collectively bargained planNo
2004-01-01Plan funding arrangement – InsuranceYes
2004-01-01Plan benefit arrangement – InsuranceYes
2003: BANK INDEPENDENT LTD 2003 form 5500 responses
2003-01-01Type of plan entitySingle employer plan
2003-01-01Submission has been amendedNo
2003-01-01This submission is the final filingNo
2003-01-01This return/report is a short plan year return/report (less than 12 months)No
2003-01-01Plan is a collectively bargained planNo
2003-01-01Plan funding arrangement – InsuranceYes
2003-01-01Plan benefit arrangement – InsuranceYes
2002: BANK INDEPENDENT LTD 2002 form 5500 responses
2002-01-01Type of plan entitySingle employer plan
2002-01-01Submission has been amendedNo
2002-01-01This submission is the final filingNo
2002-01-01This return/report is a short plan year return/report (less than 12 months)No
2002-01-01Plan is a collectively bargained planNo
2002-01-01Plan funding arrangement – InsuranceYes
2002-01-01Plan benefit arrangement – InsuranceYes

Insurance Providers Used on plan

RELIASTAR LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 67105 )
Policy contract number67746-9
Policy instance 2
Insurance contract or identification number67746-9
Number of Individuals Covered402
Insurance policy start date2012-08-01
Insurance policy end date2012-09-30
Total amount of commissions paid to insurance brokerUSD $846
Are there contracts with allocated funds for individual policies?No
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 BenefitYes
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 $5,643
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $56
Insurance broker organization code?3
Insurance broker nameBRADFORD DILLON
PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )
Policy contract number120506
Policy instance 1
Insurance contract or identification number120506
Number of Individuals Covered397
Insurance policy start date2012-01-01
Insurance policy end date2012-07-31
Total amount of commissions paid to insurance brokerUSD $3,227
Are there contracts with allocated funds for individual policies?No
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 BenefitYes
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 $54,383
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,227
Insurance broker organization code?3
Insurance broker nameSAMUEL U. HARDIE JR.
PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )
Policy contract number120506
Policy instance 1
Insurance contract or identification number120506
Number of Individuals Covered387
Insurance policy start date2011-01-01
Insurance policy end date2011-12-31
Total amount of commissions paid to insurance brokerUSD $6,961
Are there contracts with allocated funds for individual policies?No
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 BenefitYes
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 $85,365
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6,961
Insurance broker organization code?3
Insurance broker nameSAMUEL U. HARDIE JR.
PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )
Policy contract number120506
Policy instance 1
Insurance contract or identification number120506
Number of Individuals Covered346
Insurance policy start date2010-01-01
Insurance policy end date2010-12-31
Total amount of commissions paid to insurance brokerUSD $6,784
Are there contracts with allocated funds for individual policies?No
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 BenefitYes
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 $81,606
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6,784
Insurance broker organization code?3
Insurance broker nameSAMUEL U. HARDIE JR.
PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )
Policy contract number120506
Policy instance 1
Insurance contract or identification number120506
Number of Individuals Covered281
Insurance policy start date2009-01-01
Insurance policy end date2009-12-31
Total amount of commissions paid to insurance brokerUSD $6,206
Are there contracts with allocated funds for individual policies?No
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 BenefitYes
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 $64,258
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6,206
Insurance broker organization code?3
Insurance broker nameSAMUEL U. HARDIE JR.
PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )
Policy contract number120506
Policy instance 1
Insurance contract or identification number120506
Number of Individuals Covered236
Insurance policy start date2008-01-01
Insurance policy end date2008-12-31
Total amount of commissions paid to insurance brokerUSD $5,230
Are there contracts with allocated funds for individual policies?No
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 BenefitYes
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 $50,845
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,230
Insurance broker organization code?3
Insurance broker nameSAMUEL U. HARDIE JR.
PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )
Policy contract number120506
Policy instance 1
Insurance contract or identification number120506
Number of Individuals Covered220
Insurance policy start date2007-01-01
Insurance policy end date2007-12-31
Total amount of commissions paid to insurance brokerUSD $4,749
Are there contracts with allocated funds for individual policies?No
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 BenefitYes
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 $43,786
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,749
Insurance broker organization code?3
Insurance broker nameSAMUEL U. HARDIE JR.
PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )
Policy contract number120506
Policy instance 1
Insurance contract or identification number120506
Number of Individuals Covered209
Insurance policy start date2006-01-01
Insurance policy end date2006-12-31
Total amount of commissions paid to insurance brokerUSD $4,859
Are there contracts with allocated funds for individual policies?No
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 BenefitYes
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 $41,754
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $4,859
Insurance broker organization code?3
Insurance broker nameSAMUEL U. HARDIE JR.
PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )
Policy contract number120506
Policy instance 1
Insurance contract or identification number120506
Number of Individuals Covered121
Insurance policy start date2005-01-01
Insurance policy end date2005-12-31
Total amount of commissions paid to insurance brokerUSD $3,438
Are there contracts with allocated funds for individual policies?No
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 BenefitYes
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 $27,418
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,438
Insurance broker organization code?3
Insurance broker nameSAMUEL U. HARDIE JR.
PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )
Policy contract number120506
Policy instance 1
Insurance contract or identification number120506
Number of Individuals Covered122
Insurance policy start date2004-01-01
Insurance policy end date2004-12-31
Total amount of commissions paid to insurance brokerUSD $3,491
Are there contracts with allocated funds for individual policies?No
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 BenefitYes
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 $27,044
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,491
Insurance broker organization code?3
Insurance broker nameSAMUEL U. HARDIE JR.
PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )
Policy contract number120506
Policy instance 1
Insurance contract or identification number120506
Number of Individuals Covered123
Insurance policy start date2003-01-01
Insurance policy end date2003-12-31
Total amount of commissions paid to insurance brokerUSD $3,105
Are there contracts with allocated funds for individual policies?No
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 BenefitYes
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 $22,877
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,105
Insurance broker organization code?3
Insurance broker nameSAMUEL U. HARDIE JR.
PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )
Policy contract number120506
Policy instance 1
Insurance contract or identification number120506
Number of Individuals Covered111
Insurance policy start date2002-01-01
Insurance policy end date2002-12-31
Total amount of commissions paid to insurance brokerUSD $2,472
Are there contracts with allocated funds for individual policies?No
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 BenefitYes
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 $16,478
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,472
Insurance broker organization code?3
Insurance broker nameSAMUEL U. HARDIE JR.

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