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ARKANSAS UROLOGY, P.A. MEDICAL BENEFIT PLAN 401k Plan overview

Plan NameARKANSAS UROLOGY, P.A. MEDICAL BENEFIT PLAN
Plan identification number 501

ARKANSAS UROLOGY, P.A. MEDICAL BENEFIT PLAN Benefits

401k Plan TypeWelfare Benefit
Plan Features/Benefits
  • Health (other than dental or vision)
  • Life insurance
  • Dental
  • Vision
  • Temporary disability (accident and sickness)
  • Long-term disability cover

401k Sponsoring company profile

ARKANSAS UROLOGY, P.A. has sponsored the creation of one or more 401k plans.

Company Name:ARKANSAS UROLOGY, P.A.
Employer identification number (EIN):710782429
NAIC Classification:621111
NAIC Description:Offices of Physicians (except Mental Health Specialists)

Form 5500 Filing Information

Submission information for form 5500 for 401k plan ARKANSAS UROLOGY, P.A. MEDICAL BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5012021-07-01R. KEVIN NORTON2023-08-22 R. KEVIN NORTON2023-08-22
5012020-07-01R. KEVIN NORTON, CPA2022-04-18 R. KEVIN NORTON, CPA2022-04-18
5012019-07-01R. KEVIN NORTON, CPA2021-04-11 R. KEVIN NORTON, CPA2021-04-11
5012018-07-01R. KEVIN NORTON, CPA2020-01-28 R. KEVIN NORTON, CPA2020-01-28
5012017-07-01
5012016-07-01
5012015-07-01THOMAS G. MAY, CPA E. SCOT DAVIS
5012015-07-01
5012014-07-01THOMAS G. MAY, CPA
5012013-07-01
5012012-07-01E. SCOT DAVIS
5012011-07-01SCOTT LOVEDAY
5012009-07-01SYLVIA MURCHISON

Plan Statistics for ARKANSAS UROLOGY, P.A. MEDICAL BENEFIT PLAN

401k plan membership statisitcs for ARKANSAS UROLOGY, P.A. MEDICAL BENEFIT PLAN

Measure Date Value
2021: ARKANSAS UROLOGY, P.A. MEDICAL BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year2021-07-01432
Total number of active participants reported on line 7a of the Form 55002021-07-01432
Number of retired or separated participants receiving benefits2021-07-010
Number of other retired or separated participants entitled to future benefits2021-07-010
Total of all active and inactive participants2021-07-01432
2020: ARKANSAS UROLOGY, P.A. MEDICAL BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year2020-07-01265
Total number of active participants reported on line 7a of the Form 55002020-07-01356
Number of retired or separated participants receiving benefits2020-07-010
Number of other retired or separated participants entitled to future benefits2020-07-010
Total of all active and inactive participants2020-07-01356
2019: ARKANSAS UROLOGY, P.A. MEDICAL BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year2019-07-01265
Total number of active participants reported on line 7a of the Form 55002019-07-01265
Number of retired or separated participants receiving benefits2019-07-010
Number of other retired or separated participants entitled to future benefits2019-07-010
Total of all active and inactive participants2019-07-01265
2018: ARKANSAS UROLOGY, P.A. MEDICAL BENEFIT PLAN 2018 401k membership
Total participants, beginning-of-year2018-07-01242
Total number of active participants reported on line 7a of the Form 55002018-07-01265
Number of retired or separated participants receiving benefits2018-07-010
Number of other retired or separated participants entitled to future benefits2018-07-010
Total of all active and inactive participants2018-07-01265
2017: ARKANSAS UROLOGY, P.A. MEDICAL BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year2017-07-01222
Total number of active participants reported on line 7a of the Form 55002017-07-01242
Number of retired or separated participants receiving benefits2017-07-010
Number of other retired or separated participants entitled to future benefits2017-07-010
Total of all active and inactive participants2017-07-01242
2016: ARKANSAS UROLOGY, P.A. MEDICAL BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year2016-07-01207
Total number of active participants reported on line 7a of the Form 55002016-07-01222
Number of retired or separated participants receiving benefits2016-07-010
Number of other retired or separated participants entitled to future benefits2016-07-010
Total of all active and inactive participants2016-07-01222
2015: ARKANSAS UROLOGY, P.A. MEDICAL BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year2015-07-01230
Total number of active participants reported on line 7a of the Form 55002015-07-01207
Number of retired or separated participants receiving benefits2015-07-010
Number of other retired or separated participants entitled to future benefits2015-07-010
Total of all active and inactive participants2015-07-01207
2014: ARKANSAS UROLOGY, P.A. MEDICAL BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year2014-07-01221
Total number of active participants reported on line 7a of the Form 55002014-07-01230
Number of retired or separated participants receiving benefits2014-07-010
Number of other retired or separated participants entitled to future benefits2014-07-010
Total of all active and inactive participants2014-07-01230
2013: ARKANSAS UROLOGY, P.A. MEDICAL BENEFIT PLAN 2013 401k membership
Total participants, beginning-of-year2013-07-01215
Total number of active participants reported on line 7a of the Form 55002013-07-01221
Total of all active and inactive participants2013-07-01221
2012: ARKANSAS UROLOGY, P.A. MEDICAL BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year2012-07-01141
Total number of active participants reported on line 7a of the Form 55002012-07-01215
Number of retired or separated participants receiving benefits2012-07-010
Number of other retired or separated participants entitled to future benefits2012-07-010
Total of all active and inactive participants2012-07-01215
2011: ARKANSAS UROLOGY, P.A. MEDICAL BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year2011-07-01128
Total number of active participants reported on line 7a of the Form 55002011-07-01141
Number of retired or separated participants receiving benefits2011-07-010
Number of other retired or separated participants entitled to future benefits2011-07-010
Total of all active and inactive participants2011-07-01141
2009: ARKANSAS UROLOGY, P.A. MEDICAL BENEFIT PLAN 2009 401k membership
Total participants, beginning-of-year2009-07-01111
Total number of active participants reported on line 7a of the Form 55002009-07-01124
Number of retired or separated participants receiving benefits2009-07-010
Number of other retired or separated participants entitled to future benefits2009-07-010
Total of all active and inactive participants2009-07-01124

Form 5500 Responses for ARKANSAS UROLOGY, P.A. MEDICAL BENEFIT PLAN

2021: ARKANSAS UROLOGY, P.A. MEDICAL BENEFIT PLAN 2021 form 5500 responses
2021-07-01Type of plan entitySingle employer plan
2021-07-01Plan funding arrangement – InsuranceYes
2021-07-01Plan funding arrangement – General assets of the sponsorYes
2021-07-01Plan benefit arrangement – InsuranceYes
2021-07-01Plan benefit arrangement – General assets of the sponsorYes
2020: ARKANSAS UROLOGY, P.A. MEDICAL BENEFIT PLAN 2020 form 5500 responses
2020-07-01Type of plan entitySingle employer plan
2020-07-01Plan funding arrangement – InsuranceYes
2020-07-01Plan funding arrangement – General assets of the sponsorYes
2020-07-01Plan benefit arrangement – InsuranceYes
2020-07-01Plan benefit arrangement – General assets of the sponsorYes
2019: ARKANSAS UROLOGY, P.A. MEDICAL BENEFIT PLAN 2019 form 5500 responses
2019-07-01Type of plan entitySingle employer plan
2019-07-01Plan funding arrangement – InsuranceYes
2019-07-01Plan funding arrangement – General assets of the sponsorYes
2019-07-01Plan benefit arrangement – InsuranceYes
2019-07-01Plan benefit arrangement – General assets of the sponsorYes
2018: ARKANSAS UROLOGY, P.A. MEDICAL BENEFIT PLAN 2018 form 5500 responses
2018-07-01Type of plan entitySingle employer plan
2018-07-01Plan funding arrangement – InsuranceYes
2018-07-01Plan funding arrangement – General assets of the sponsorYes
2018-07-01Plan benefit arrangement – InsuranceYes
2018-07-01Plan benefit arrangement – General assets of the sponsorYes
2017: ARKANSAS UROLOGY, P.A. MEDICAL BENEFIT PLAN 2017 form 5500 responses
2017-07-01Type of plan entitySingle employer plan
2017-07-01Plan funding arrangement – InsuranceYes
2017-07-01Plan funding arrangement – General assets of the sponsorYes
2017-07-01Plan benefit arrangement – InsuranceYes
2017-07-01Plan benefit arrangement – General assets of the sponsorYes
2016: ARKANSAS UROLOGY, P.A. MEDICAL BENEFIT PLAN 2016 form 5500 responses
2016-07-01Type of plan entitySingle employer plan
2016-07-01Plan funding arrangement – InsuranceYes
2016-07-01Plan funding arrangement – General assets of the sponsorYes
2016-07-01Plan benefit arrangement – InsuranceYes
2016-07-01Plan benefit arrangement – General assets of the sponsorYes
2015: ARKANSAS UROLOGY, P.A. MEDICAL BENEFIT PLAN 2015 form 5500 responses
2015-07-01Type of plan entitySingle employer plan
2015-07-01Submission has been amendedYes
2015-07-01Plan funding arrangement – InsuranceYes
2015-07-01Plan funding arrangement – General assets of the sponsorYes
2015-07-01Plan benefit arrangement – InsuranceYes
2015-07-01Plan benefit arrangement – General assets of the sponsorYes
2014: ARKANSAS UROLOGY, P.A. MEDICAL BENEFIT PLAN 2014 form 5500 responses
2014-07-01Type of plan entitySingle employer plan
2014-07-01Plan funding arrangement – InsuranceYes
2014-07-01Plan funding arrangement – General assets of the sponsorYes
2014-07-01Plan benefit arrangement – InsuranceYes
2014-07-01Plan benefit arrangement – General assets of the sponsorYes
2013: ARKANSAS UROLOGY, P.A. MEDICAL BENEFIT PLAN 2013 form 5500 responses
2013-07-01Type of plan entitySingle employer plan
2013-07-01Plan funding arrangement – InsuranceYes
2013-07-01Plan funding arrangement – General assets of the sponsorYes
2013-07-01Plan benefit arrangement – InsuranceYes
2013-07-01Plan benefit arrangement – General assets of the sponsorYes
2012: ARKANSAS UROLOGY, P.A. MEDICAL BENEFIT PLAN 2012 form 5500 responses
2012-07-01Type of plan entitySingle employer plan
2012-07-01Plan funding arrangement – InsuranceYes
2012-07-01Plan funding arrangement – General assets of the sponsorYes
2012-07-01Plan benefit arrangement – InsuranceYes
2012-07-01Plan benefit arrangement – General assets of the sponsorYes
2011: ARKANSAS UROLOGY, P.A. MEDICAL BENEFIT PLAN 2011 form 5500 responses
2011-07-01Type of plan entitySingle employer plan
2011-07-01Plan funding arrangement – InsuranceYes
2011-07-01Plan funding arrangement – General assets of the sponsorYes
2011-07-01Plan benefit arrangement – InsuranceYes
2011-07-01Plan benefit arrangement – General assets of the sponsorYes
2009: ARKANSAS UROLOGY, P.A. MEDICAL BENEFIT PLAN 2009 form 5500 responses
2009-07-01Type of plan entitySingle employer plan
2009-07-01This submission is the final filingNo
2009-07-01Plan funding arrangement – InsuranceYes
2009-07-01Plan funding arrangement – General assets of the sponsorYes
2009-07-01Plan benefit arrangement – InsuranceYes
2009-07-01Plan benefit arrangement – General assets of the sponsorYes

Insurance Providers Used on plan

SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )
Policy contract numberLIF94049
Policy instance 10
Insurance contract or identification numberLIF94049
Number of Individuals Covered21
Insurance policy start date2021-07-01
Insurance policy end date2022-06-30
Total amount of commissions paid to insurance brokerUSD $1,955
Total amount of fees paid to insurance companyUSD $180
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $21,716
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,458
Insurance broker organization code?3
Amount paid for insurance broker fees180
DELTA DENTAL PLAN OF ARKANSAS (National Association of Insurance Commissioners NAIC id number: 47155 )
Policy contract number000004530
Policy instance 1
Insurance contract or identification number000004530
Number of Individuals Covered432
Insurance policy start date2021-07-01
Insurance policy end date2022-06-30
Dental Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Insurance broker organization code?3
ARKANSAS BLUE CROSS BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 83470 )
Policy contract number83470
Policy instance 2
Insurance contract or identification number83470
Number of Individuals Covered230
Insurance policy start date2021-07-01
Insurance policy end date2022-06-30
Total amount of fees paid to insurance companyUSD $199,824
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,539,732
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Amount paid for insurance broker fees199824
Additional information about fees paid to insurance brokerMISCELLANEOUS ADMINISTRATIVE
Insurance broker organization code?5
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number000000428300
Policy instance 3
Insurance contract or identification number000000428300
Number of Individuals Covered288
Insurance policy start date2021-07-01
Insurance policy end date2022-06-30
Total amount of commissions paid to insurance brokerUSD $10,716
Total amount of fees paid to insurance companyUSD $2,025
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $97,355
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $10,716
Amount paid for insurance broker fees2025
Insurance broker organization code?3
DELTA DENTAL PLAN OF ARKANSAS (National Association of Insurance Commissioners NAIC id number: 47155 )
Policy contract number00004530V
Policy instance 4
Insurance contract or identification number00004530V
Number of Individuals Covered315
Insurance policy start date2021-07-01
Insurance policy end date2022-06-30
Total amount of commissions paid to insurance brokerUSD $3,608
Vision Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,608
Insurance broker organization code?3
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number00557857
Policy instance 5
Insurance contract or identification number00557857
Number of Individuals Covered131
Insurance policy start date2021-07-01
Insurance policy end date2022-06-30
Total amount of commissions paid to insurance brokerUSD $14,293
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $73,903
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $14,293
Additional information about fees paid to insurance brokerMISCELLANEOUS ADMINISTRATIVE
Insurance broker organization code?3
MONY (National Association of Insurance Commissioners NAIC id number: 78077 )
Policy contract number007842
Policy instance 6
Insurance contract or identification number007842
Number of Individuals Covered116
Insurance policy start date2021-07-01
Insurance policy end date2022-06-30
Total amount of commissions paid to insurance brokerUSD $15,558
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $63,048
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $15,558
Insurance broker organization code?3
PRE-PAID LEGAL SERVICES DBA LEGAL SHIELD (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number202727
Policy instance 7
Insurance contract or identification number202727
Number of Individuals Covered20
Insurance policy start date2021-07-01
Insurance policy end date2022-06-30
Total amount of commissions paid to insurance brokerUSD $307
Other welfare benefits providedLEGAL SERVICES PLAN MEMBERSHIPS
Welfare Benefit Premiums Paid to CarrierUSD $2,685
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $232
Insurance broker organization code?4
SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )
Policy contract number941663
Policy instance 8
Insurance contract or identification number941663
Number of Individuals Covered242
Insurance policy start date2021-07-01
Insurance policy end date2022-06-30
Total amount of commissions paid to insurance brokerUSD $29,553
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $355,681
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $29,553
5 STAR LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 77879 )
Policy contract number02728
Policy instance 9
Insurance contract or identification number02728
Number of Individuals Covered97
Insurance policy start date2021-07-01
Insurance policy end date2022-06-30
Total amount of commissions paid to insurance brokerUSD $16,835
Life Insurance Welfare BenefitYes
Other welfare benefits providedGROUP CRITICAL ILLNESS
Welfare Benefit Premiums Paid to CarrierUSD $42,083
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $13,280
Insurance broker organization code?3
ARKANSAS BLUE CROSS BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 83470 )
Policy contract number83470
Policy instance 2
Insurance contract or identification number83470
Number of Individuals Covered199
Insurance policy start date2020-07-01
Insurance policy end date2021-06-30
Total amount of fees paid to insurance companyUSD $151,128
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,214,302
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Amount paid for insurance broker fees151128
Additional information about fees paid to insurance brokerMISCELLANEOUS ADMINISTRATIVE
Insurance broker organization code?5
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number000000428300
Policy instance 3
Insurance contract or identification number000000428300
Number of Individuals Covered269
Insurance policy start date2020-07-01
Insurance policy end date2021-06-30
Total amount of commissions paid to insurance brokerUSD $18,054
Total amount of fees paid to insurance companyUSD $7,222
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $182,748
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $18,054
Amount paid for insurance broker fees7222
Insurance broker organization code?3
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract numberE3955739
Policy instance 4
Insurance contract or identification numberE3955739
Number of Individuals Covered138
Insurance policy start date2020-07-01
Insurance policy end date2021-06-30
Total amount of commissions paid to insurance brokerUSD $6,399
Total amount of fees paid to insurance companyUSD $187
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $22,570
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,393
Additional information about fees paid to insurance brokerMISCELLANEOUS ADMINISTRATIVE
Insurance broker organization code?3
Amount paid for insurance broker fees51
DELTA DENTAL PLAN OF ARKANSAS (National Association of Insurance Commissioners NAIC id number: 47155 )
Policy contract number00004530V
Policy instance 5
Insurance contract or identification number00004530V
Number of Individuals Covered315
Insurance policy start date2020-07-01
Insurance policy end date2021-06-30
Total amount of commissions paid to insurance brokerUSD $2,667
Vision Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,667
Insurance broker organization code?3
MONY (National Association of Insurance Commissioners NAIC id number: 78077 )
Policy contract number007842
Policy instance 7
Insurance contract or identification number007842
Number of Individuals Covered104
Insurance policy start date2020-07-01
Insurance policy end date2021-07-01
Total amount of commissions paid to insurance brokerUSD $15,897
Total amount of fees paid to insurance companyUSD $3,871
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $68,238
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $15,897
Amount paid for insurance broker fees3871
Additional information about fees paid to insurance brokerBONUS
Insurance broker organization code?3
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number00557857
Policy instance 6
Insurance contract or identification number00557857
Number of Individuals Covered123
Insurance policy start date2020-07-01
Insurance policy end date2021-06-30
Total amount of commissions paid to insurance brokerUSD $76,142
Total amount of fees paid to insurance companyUSD $2,513
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $81,096
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $76,142
Amount paid for insurance broker fees2513
Additional information about fees paid to insurance brokerMISCELLANEOUS ADMINISTRATIVE
Insurance broker organization code?3
PRE-PAID LEGAL SERVICES DBA LEGAL SHIELD (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number202727
Policy instance 8
Insurance contract or identification number202727
Number of Individuals Covered17
Insurance policy start date2020-07-01
Insurance policy end date2021-06-30
Total amount of commissions paid to insurance brokerUSD $728
Other welfare benefits providedLEGAL SERVICES PLAN MEMBERSHIPS
Welfare Benefit Premiums Paid to CarrierUSD $2,455
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $659
Insurance broker organization code?4
SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )
Policy contract numberLIF94049
Policy instance 9
Insurance contract or identification numberLIF94049
Number of Individuals Covered22
Insurance policy start date2020-06-01
Insurance policy end date2021-07-01
Total amount of commissions paid to insurance brokerUSD $2,267
Total amount of fees paid to insurance companyUSD $180
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $25,187
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,267
Insurance broker organization code?3
Amount paid for insurance broker fees180
Additional information about fees paid to insurance brokerADMINISTRATIVE FEE
5 STAR LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 77879 )
Policy contract number02728
Policy instance 10
Insurance contract or identification number02728
Number of Individuals Covered101
Insurance policy start date2020-07-01
Insurance policy end date2021-06-30
Total amount of commissions paid to insurance brokerUSD $11,675
Life Insurance Welfare BenefitYes
Other welfare benefits providedGROUP CRITICAL ILLNESS
Welfare Benefit Premiums Paid to CarrierUSD $6,292
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $11,334
Insurance broker organization code?3
DELTA DENTAL PLAN OF ARKANSAS (National Association of Insurance Commissioners NAIC id number: 47155 )
Policy contract number000004530
Policy instance 1
Insurance contract or identification number000004530
Number of Individuals Covered356
Insurance policy start date2020-07-01
Insurance policy end date2021-06-30
Dental Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Insurance broker organization code?3
DELTA DENTAL PLAN OF ARKANSAS (National Association of Insurance Commissioners NAIC id number: 47155 )
Policy contract number000004530
Policy instance 1
Insurance contract or identification number000004530
Number of Individuals Covered265
Insurance policy start date2019-07-01
Insurance policy end date2020-06-30
Dental Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
ARKANSAS BLUE CROSS BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 83470 )
Policy contract number83470
Policy instance 2
Insurance contract or identification number83470
Number of Individuals Covered172
Insurance policy start date2019-07-01
Insurance policy end date2020-06-30
Total amount of fees paid to insurance companyUSD $115,301
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,120,680
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Amount paid for insurance broker fees115301
Additional information about fees paid to insurance brokerMISCELLANEOUS ADMINISTRATIVE
Insurance broker organization code?5
QBE A&H (National Association of Insurance Commissioners NAIC id number: 10219 )
Policy contract numberLGS01081-17
Policy instance 3
Insurance contract or identification numberLGS01081-17
Number of Individuals Covered167
Insurance policy start date2019-07-01
Insurance policy end date2020-06-30
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $241,936
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract numberE3955739
Policy instance 4
Insurance contract or identification numberE3955739
Number of Individuals Covered131
Insurance policy start date2019-07-01
Insurance policy end date2020-06-30
Total amount of commissions paid to insurance brokerUSD $33,541
Total amount of fees paid to insurance companyUSD $1,252
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $116,932
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $12,463
Additional information about fees paid to insurance brokerMISCELLANEOUS ADMINISTRATIVE
Insurance broker organization code?3
Amount paid for insurance broker fees764
DELTA DENTAL PLAN OF ARKANSAS (National Association of Insurance Commissioners NAIC id number: 47155 )
Policy contract number00004530V
Policy instance 5
Insurance contract or identification number00004530V
Number of Individuals Covered251
Insurance policy start date2019-07-01
Insurance policy end date2020-06-30
Total amount of commissions paid to insurance brokerUSD $2,177
Vision Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,177
Additional information about fees paid to insurance brokerMISCELLANEOUS ADMINISTRATIVE
Insurance broker organization code?3
DELTA DENTAL PLAN OF ARKANSAS (National Association of Insurance Commissioners NAIC id number: 47155 )
Policy contract number00004530V
Policy instance 5
Insurance contract or identification number00004530V
Number of Individuals Covered251
Insurance policy start date2018-07-01
Insurance policy end date2019-06-30
Total amount of commissions paid to insurance brokerUSD $2,177
Vision Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,177
Additional information about fees paid to insurance brokerMISCELLANEOUS ADMINISTRATIVE
Insurance broker organization code?3
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract numberE3955739
Policy instance 4
Insurance contract or identification numberE3955739
Number of Individuals Covered131
Insurance policy start date2018-07-01
Insurance policy end date2019-06-30
Total amount of commissions paid to insurance brokerUSD $33,541
Total amount of fees paid to insurance companyUSD $1,252
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $116,932
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $12,463
Additional information about fees paid to insurance brokerMISCELLANEOUS ADMINISTRATIVE
Insurance broker organization code?3
Amount paid for insurance broker fees764
QBE A&H (National Association of Insurance Commissioners NAIC id number: 10219 )
Policy contract numberLGS01081-17
Policy instance 3
Insurance contract or identification numberLGS01081-17
Number of Individuals Covered167
Insurance policy start date2018-07-01
Insurance policy end date2019-06-30
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $241,936
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
ARKANSAS BLUE CROSS BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 83470 )
Policy contract number83470
Policy instance 2
Insurance contract or identification number83470
Number of Individuals Covered172
Insurance policy start date2018-07-01
Insurance policy end date2019-06-30
Total amount of fees paid to insurance companyUSD $115,301
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,120,680
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Amount paid for insurance broker fees115301
Additional information about fees paid to insurance brokerMISCELLANEOUS ADMINISTRATIVE
Insurance broker organization code?5
DELTA DENTAL PLAN OF ARKANSAS (National Association of Insurance Commissioners NAIC id number: 47155 )
Policy contract number000004530
Policy instance 1
Insurance contract or identification number000004530
Number of Individuals Covered265
Insurance policy start date2018-07-01
Insurance policy end date2019-06-30
Dental Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Insurance broker organization code?3
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract numberE3955739
Policy instance 5
Insurance contract or identification numberE3955739
Number of Individuals Covered107
Insurance policy start date2017-07-01
Insurance policy end date2018-06-30
Total amount of commissions paid to insurance brokerUSD $20,153
Total amount of fees paid to insurance companyUSD $1,163
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $86,497
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 fees64
Additional information about fees paid to insurance brokerMISCELLANEOUS ADMINISTRATIVE
Insurance broker organization code?3
Insurance broker nameJENNIFER HUNTER
QBE A&H (National Association of Insurance Commissioners NAIC id number: 10219 )
Policy contract numberLGS01081-17
Policy instance 4
Insurance contract or identification numberLGS01081-17
Number of Individuals Covered143
Insurance policy start date2017-07-01
Insurance policy end date2018-06-30
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $197,521
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
ARKANSAS BLUE CROSS BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 83470 )
Policy contract number83470
Policy instance 3
Insurance contract or identification number83470
Number of Individuals Covered157
Insurance policy start date2017-07-01
Insurance policy end date2018-06-30
Total amount of fees paid to insurance companyUSD $97,228
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $717,249
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Amount paid for insurance broker fees97228
Additional information about fees paid to insurance brokerMISCELLANEOUS ADMINISTRATIVE
Insurance broker organization code?5
Insurance broker nameBLUEADVANTAGE ADMINISTRATORS OF ARK
DELTA DENTAL PLAN OF ARKANSAS (National Association of Insurance Commissioners NAIC id number: 47155 )
Policy contract number000004530
Policy instance 2
Insurance contract or identification number000004530
Number of Individuals Covered242
Insurance policy start date2017-07-01
Insurance policy end date2018-06-30
Dental Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number12289209
Policy instance 1
Insurance contract or identification number12289209
Number of Individuals Covered126
Insurance policy start date2017-07-01
Insurance policy end date2018-06-30
Total amount of commissions paid to insurance brokerUSD $1,384
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $23,330
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,384
Insurance broker organization code?3
Insurance broker nameJTS FINANCIAL SERVICES, LLC
QBE A&H (National Association of Insurance Commissioners NAIC id number: 10219 )
Policy contract numberLGS01081-14
Policy instance 5
Insurance contract or identification numberLGS01081-14
Number of Individuals Covered1458
Insurance policy start date2015-07-01
Insurance policy end date2016-06-30
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $147,977
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
ARKANSAS BLUE CROSS BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 83470 )
Policy contract number83470
Policy instance 4
Insurance contract or identification number83470
Number of Individuals Covered120
Insurance policy start date2015-07-01
Insurance policy end date2016-06-30
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $81,034
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 )
Policy contract number1045110
Policy instance 3
Insurance contract or identification number1045110
Number of Individuals Covered142
Insurance policy start date2015-07-01
Insurance policy end date2016-06-30
Total amount of commissions paid to insurance brokerUSD $12,258
Total amount of fees paid to insurance companyUSD $373
Life Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $120,476
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,755
Insurance broker organization code?3
Amount paid for insurance broker fees373
Additional information about fees paid to insurance brokerBONUS
Insurance broker nameACRISURE LLC
DELTA DENTAL PLAN OF ARKANSAS (National Association of Insurance Commissioners NAIC id number: 47155 )
Policy contract number000004530
Policy instance 2
Insurance contract or identification number000004530
Number of Individuals Covered207
Insurance policy start date2015-07-01
Insurance policy end date2016-06-30
Dental Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Insurance broker organization code?3
Insurance broker nameJTS FINANCIAL SERVICES
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number12289209
Policy instance 1
Insurance contract or identification number12289209
Number of Individuals Covered99
Insurance policy start date2015-07-01
Insurance policy end date2016-06-30
Total amount of commissions paid to insurance brokerUSD $1,029
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $18,320
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,029
Insurance broker organization code?3
Insurance broker nameJTS FINANCIAL SERVICES, LLC
COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )
Policy contract numberE3955739
Policy instance 6
Insurance contract or identification numberE3955739
Number of Individuals Covered85
Insurance policy start date2015-07-01
Insurance policy end date2016-06-30
Total amount of commissions paid to insurance brokerUSD $20,947
Total amount of fees paid to insurance companyUSD $684
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $87,098
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $6,539
Insurance broker organization code?3
Amount paid for insurance broker fees182
Additional information about fees paid to insurance brokerMISC
Insurance broker nameBARNETT BENEFITS GROUP INC
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number12289209
Policy instance 1
Insurance contract or identification number12289209
Number of Individuals Covered124
Insurance policy start date2014-07-01
Insurance policy end date2015-06-30
Total amount of commissions paid to insurance brokerUSD $1,077
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $18,414
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,077
Insurance broker organization code?3
Insurance broker nameJTS FINANCIAL SERVICES, LLC
DELTA DENTAL PLAN OF ARKANSAS (National Association of Insurance Commissioners NAIC id number: 47155 )
Policy contract number000004530
Policy instance 2
Insurance contract or identification number000004530
Number of Individuals Covered230
Insurance policy start date2014-07-01
Insurance policy end date2015-06-30
Dental Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 )
Policy contract number1045110
Policy instance 3
Insurance contract or identification number1045110
Number of Individuals Covered158
Insurance policy start date2014-07-01
Insurance policy end date2015-06-30
Total amount of commissions paid to insurance brokerUSD $10,774
Total amount of fees paid to insurance companyUSD $4,784
Life Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $105,932
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $10,774
Amount paid for insurance broker fees4784
Additional information about fees paid to insurance brokerBONUS
Insurance broker organization code?3
Insurance broker nameTHE HATCHER AGENCY
ARKANSAS BLUE CROSS BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 83470 )
Policy contract number83470
Policy instance 4
Insurance contract or identification number83470
Number of Individuals Covered138
Insurance policy start date2014-07-01
Insurance policy end date2015-06-30
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $83,354
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
QBE A&H (National Association of Insurance Commissioners NAIC id number: 10219 )
Policy contract numberLGS01081-14
Policy instance 5
Insurance contract or identification numberLGS01081-14
Number of Individuals Covered985
Insurance policy start date2014-07-01
Insurance policy end date2015-06-30
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $120,160
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number12289209
Policy instance 2
Insurance contract or identification number12289209
Number of Individuals Covered88
Insurance policy start date2013-07-01
Insurance policy end date2014-06-30
Total amount of commissions paid to insurance brokerUSD $954
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
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $15,527
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $954
Insurance broker organization code?3
Insurance broker nameJTS FINANCIAL SERVICES, LLC
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract numberR0100123
Policy instance 1
Insurance contract or identification numberR0100123
Number of Individuals Covered134
Insurance policy start date2013-07-01
Insurance policy end date2014-06-30
Total amount of commissions paid to insurance brokerUSD $456
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
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $4,546
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $456
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameJOHN THOMAS STARLING
DELTA DENTAL PLAN OF ARKANSAS (National Association of Insurance Commissioners NAIC id number: 47155 )
Policy contract number000004530
Policy instance 3
Insurance contract or identification number000004530
Number of Individuals Covered221
Insurance policy start date2013-07-01
Insurance policy end date2014-06-30
Total amount of commissions paid to insurance brokerUSD $0
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
Dental Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
HCC LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 92711 )
Policy contract numberHCL30526
Policy instance 5
Insurance contract or identification numberHCL30526
Number of Individuals Covered135
Insurance policy start date2013-07-01
Insurance policy end date2014-06-30
Total amount of commissions paid to insurance brokerUSD $0
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
Welfare Benefit Premiums Paid to CarrierUSD $157,506
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
QCA HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 95448 )
Policy contract number90002
Policy instance 4
Insurance contract or identification number90002
Number of Individuals Covered202
Insurance policy start date2013-07-01
Insurance policy end date2014-06-30
Total amount of commissions paid to insurance brokerUSD $14,918
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
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $44,948
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $14,918
Additional information about fees paid to insurance brokerADMINISTRATIVE FEES
Insurance broker organization code?3
Insurance broker nameJTS FINANCIAL SERVICES, LLC
QCA HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 95448 )
Policy contract number90002
Policy instance 4
Insurance contract or identification number90002
Number of Individuals Covered207
Insurance policy start date2012-07-01
Insurance policy end date2013-06-30
Total amount of commissions paid to insurance brokerUSD $15,709
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
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $44,072
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $15,709
Insurance broker organization code?3
Insurance broker nameJTS FINANCIAL SERVICES, LLC
DELTA DENTAL PLAN OF ARKANSAS (National Association of Insurance Commissioners NAIC id number: 47155 )
Policy contract number000004530
Policy instance 3
Insurance contract or identification number000004530
Number of Individuals Covered215
Insurance policy start date2012-07-01
Insurance policy end date2013-06-30
Total amount of commissions paid to insurance brokerUSD $0
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
Dental Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number12289209
Policy instance 2
Insurance contract or identification number12289209
Number of Individuals Covered90
Insurance policy start date2012-07-01
Insurance policy end date2013-06-30
Total amount of commissions paid to insurance brokerUSD $912
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
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $14,797
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $787
Insurance broker organization code?3
Insurance broker namePINNACLE BENEFIT SOLUTIONS LLC
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract numberR0100123
Policy instance 1
Insurance contract or identification numberR0100123
Number of Individuals Covered140
Insurance policy start date2012-07-01
Insurance policy end date2013-06-30
Total amount of commissions paid to insurance brokerUSD $451
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
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $4,511
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $412
Insurance broker organization code?3
Insurance broker namePINNACLE BENEFIT SOLUTIONS LLC
HCC LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 92711 )
Policy contract numberHCL12884
Policy instance 3
Insurance contract or identification numberHCL12884
Number of Individuals Covered141
Insurance policy start date2011-07-01
Insurance policy end date2012-06-30
Total amount of commissions paid to insurance brokerUSD $28,655
Total amount of fees paid to insurance companyUSD $4,202
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $210,095
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number12289209
Policy instance 2
Insurance contract or identification number12289209
Number of Individuals Covered97
Insurance policy start date2011-07-01
Insurance policy end date2012-06-30
Total amount of commissions paid to insurance brokerUSD $132
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
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $14,962
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract numberR0100123
Policy instance 1
Insurance contract or identification numberR0100123
Number of Individuals Covered140
Insurance policy start date2011-07-01
Insurance policy end date2012-06-30
Total amount of commissions paid to insurance brokerUSD $450
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
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $4,498
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
HCC LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 92711 )
Policy contract numberHCL12884
Policy instance 3
Insurance contract or identification numberHCL12884
Number of Individuals Covered128
Insurance policy start date2010-07-01
Insurance policy end date2011-06-30
Total amount of commissions paid to insurance brokerUSD $29,565
Total amount of fees paid to insurance companyUSD $4,106
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $205,306
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $29,565
Amount paid for insurance broker fees4106
Additional information about fees paid to insurance brokerOVERRIDE FEE
Insurance broker organization code?5
Insurance broker nameCORESOURCE, INC.
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number12289209
Policy instance 2
Insurance contract or identification number12289209
Number of Individuals Covered81
Insurance policy start date2010-07-01
Insurance policy end date2011-06-30
Total amount of commissions paid to insurance brokerUSD $0
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
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $12,298
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )
Policy contract numberR0100123
Policy instance 1
Insurance contract or identification numberR0100123
Number of Individuals Covered122
Insurance policy start date2010-07-01
Insurance policy end date2011-06-30
Total amount of commissions paid to insurance brokerUSD $404
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
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $4,388
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $404
Insurance broker organization code?5
Insurance broker nameCORESOURCE, INC.

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