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FIESTA MART, INC. EMPLOYEE HEALTH PLAN 401k Plan overview

Plan NameFIESTA MART, INC. EMPLOYEE HEALTH PLAN
Plan identification number 501

FIESTA MART, INC. EMPLOYEE HEALTH PLAN Benefits

401k Plan TypeWelfare Benefit
Plan Features/Benefits
  • Health (other than dental or vision)
  • Life insurance
  • Dental
  • Vision
  • Temporary disability (accident and sickness)
  • Death benefits (include travel accident but not life insurance)
  • Other welfare benefit cover

401k Sponsoring company profile

FIESTA MART, L.L.C. has sponsored the creation of one or more 401k plans.

Company Name:FIESTA MART, L.L.C.
Employer identification number (EIN):741874033
NAIC Classification:445110
NAIC Description:Supermarkets and Other Grocery (except Convenience) Stores

Form 5500 Filing Information

Submission information for form 5500 for 401k plan FIESTA MART, INC. EMPLOYEE HEALTH PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5012021-10-01JACK HOOK2023-04-25
5012020-10-01JACK HOOK2022-07-12
5012019-10-01JACK HOOK2021-07-08
5012019-01-01JACK HOOK2020-07-10
5012018-01-01
5012017-01-01
5012016-01-01STACY WALKER
5012015-01-01STACY WALKER
5012014-01-01STACY WALKER
5012013-01-01STACY WALKER STACY WALKER2014-07-18
5012012-01-01STACY WALKER STACY WALKER2013-07-31
5012011-01-01STACY WALKER STACY WALKER2012-07-24
5012010-01-01SATCY WALKER LOUIS KATOPODIS2011-07-12
5012009-01-01STACY WALKER LOUIS KATOPODIS2010-09-24

Plan Statistics for FIESTA MART, INC. EMPLOYEE HEALTH PLAN

401k plan membership statisitcs for FIESTA MART, INC. EMPLOYEE HEALTH PLAN

Measure Date Value
2021: FIESTA MART, INC. EMPLOYEE HEALTH PLAN 2021 401k membership
Total participants, beginning-of-year2021-10-011,654
Total number of active participants reported on line 7a of the Form 55002021-10-011,225
Number of retired or separated participants receiving benefits2021-10-010
Number of other retired or separated participants entitled to future benefits2021-10-010
Total of all active and inactive participants2021-10-011,225
Number of employers contributing to the scheme2021-10-010
2020: FIESTA MART, INC. EMPLOYEE HEALTH PLAN 2020 401k membership
Total participants, beginning-of-year2020-10-011,963
Total number of active participants reported on line 7a of the Form 55002020-10-011,648
Number of retired or separated participants receiving benefits2020-10-016
Number of other retired or separated participants entitled to future benefits2020-10-010
Total of all active and inactive participants2020-10-011,654
Number of employers contributing to the scheme2020-10-010
2019: FIESTA MART, INC. EMPLOYEE HEALTH PLAN 2019 401k membership
Total participants, beginning-of-year2019-10-012,252
Total number of active participants reported on line 7a of the Form 55002019-10-011,956
Number of retired or separated participants receiving benefits2019-10-017
Number of other retired or separated participants entitled to future benefits2019-10-010
Total of all active and inactive participants2019-10-011,963
Number of employers contributing to the scheme2019-10-010
Total participants, beginning-of-year2019-01-012,554
Total number of active participants reported on line 7a of the Form 55002019-01-012,243
Number of retired or separated participants receiving benefits2019-01-019
Number of other retired or separated participants entitled to future benefits2019-01-010
Total of all active and inactive participants2019-01-012,252
Number of employers contributing to the scheme2019-01-010
2018: FIESTA MART, INC. EMPLOYEE HEALTH PLAN 2018 401k membership
Total participants, beginning-of-year2018-01-012,630
Total number of active participants reported on line 7a of the Form 55002018-01-012,538
Number of retired or separated participants receiving benefits2018-01-0116
Number of other retired or separated participants entitled to future benefits2018-01-010
Total of all active and inactive participants2018-01-012,554
Number of employers contributing to the scheme2018-01-010
2017: FIESTA MART, INC. EMPLOYEE HEALTH PLAN 2017 401k membership
Total participants, beginning-of-year2017-01-013,354
Total number of active participants reported on line 7a of the Form 55002017-01-012,614
Number of retired or separated participants receiving benefits2017-01-0116
Number of other retired or separated participants entitled to future benefits2017-01-010
Total of all active and inactive participants2017-01-012,630
2016: FIESTA MART, INC. EMPLOYEE HEALTH PLAN 2016 401k membership
Total participants, beginning-of-year2016-01-013,234
Total number of active participants reported on line 7a of the Form 55002016-01-013,329
Number of retired or separated participants receiving benefits2016-01-0125
Number of other retired or separated participants entitled to future benefits2016-01-010
Total of all active and inactive participants2016-01-013,354
2015: FIESTA MART, INC. EMPLOYEE HEALTH PLAN 2015 401k membership
Total participants, beginning-of-year2015-01-013,319
Total number of active participants reported on line 7a of the Form 55002015-01-013,216
Number of retired or separated participants receiving benefits2015-01-0118
Number of other retired or separated participants entitled to future benefits2015-01-010
Total of all active and inactive participants2015-01-013,234
2014: FIESTA MART, INC. EMPLOYEE HEALTH PLAN 2014 401k membership
Total participants, beginning-of-year2014-01-012,949
Total number of active participants reported on line 7a of the Form 55002014-01-013,304
Number of retired or separated participants receiving benefits2014-01-0115
Number of other retired or separated participants entitled to future benefits2014-01-010
Total of all active and inactive participants2014-01-013,319
2013: FIESTA MART, INC. EMPLOYEE HEALTH PLAN 2013 401k membership
Total participants, beginning-of-year2013-01-013,102
Total number of active participants reported on line 7a of the Form 55002013-01-012,949
Number of retired or separated participants receiving benefits2013-01-010
Total of all active and inactive participants2013-01-012,949
2012: FIESTA MART, INC. EMPLOYEE HEALTH PLAN 2012 401k membership
Total participants, beginning-of-year2012-01-013,118
Total number of active participants reported on line 7a of the Form 55002012-01-013,102
Number of retired or separated participants receiving benefits2012-01-010
Total of all active and inactive participants2012-01-013,102
2011: FIESTA MART, INC. EMPLOYEE HEALTH PLAN 2011 401k membership
Total participants, beginning-of-year2011-01-013,168
Total number of active participants reported on line 7a of the Form 55002011-01-012,946
Number of retired or separated participants receiving benefits2011-01-017
Total of all active and inactive participants2011-01-012,953
2010: FIESTA MART, INC. EMPLOYEE HEALTH PLAN 2010 401k membership
Total participants, beginning-of-year2010-01-013,076
Total number of active participants reported on line 7a of the Form 55002010-01-013,164
Number of retired or separated participants receiving benefits2010-01-014
Number of other retired or separated participants entitled to future benefits2010-01-010
Total of all active and inactive participants2010-01-013,168
2009: FIESTA MART, INC. EMPLOYEE HEALTH PLAN 2009 401k membership
Total participants, beginning-of-year2009-01-012,987
Total number of active participants reported on line 7a of the Form 55002009-01-013,074
Number of retired or separated participants receiving benefits2009-01-012
Number of other retired or separated participants entitled to future benefits2009-01-010
Total of all active and inactive participants2009-01-013,076

Form 5500 Responses for FIESTA MART, INC. EMPLOYEE HEALTH PLAN

2021: FIESTA MART, INC. EMPLOYEE HEALTH PLAN 2021 form 5500 responses
2021-10-01Type of plan entitySingle employer plan
2021-10-01Plan funding arrangement – InsuranceYes
2021-10-01Plan funding arrangement – General assets of the sponsorYes
2021-10-01Plan benefit arrangement – InsuranceYes
2021-10-01Plan benefit arrangement – General assets of the sponsorYes
2020: FIESTA MART, INC. EMPLOYEE HEALTH PLAN 2020 form 5500 responses
2020-10-01Type of plan entitySingle employer plan
2020-10-01Plan funding arrangement – InsuranceYes
2020-10-01Plan funding arrangement – General assets of the sponsorYes
2020-10-01Plan benefit arrangement – InsuranceYes
2020-10-01Plan benefit arrangement – General assets of the sponsorYes
2019: FIESTA MART, INC. EMPLOYEE HEALTH PLAN 2019 form 5500 responses
2019-10-01Type of plan entitySingle employer plan
2019-10-01Plan funding arrangement – InsuranceYes
2019-10-01Plan funding arrangement – General assets of the sponsorYes
2019-10-01Plan benefit arrangement – InsuranceYes
2019-10-01Plan benefit arrangement – General assets of the sponsorYes
2019-01-01Type of plan entitySingle employer plan
2019-01-01This return/report is a short plan year return/report (less than 12 months)Yes
2019-01-01Plan funding arrangement – InsuranceYes
2019-01-01Plan funding arrangement – General assets of the sponsorYes
2019-01-01Plan benefit arrangement – InsuranceYes
2019-01-01Plan benefit arrangement – General assets of the sponsorYes
2018: FIESTA MART, INC. EMPLOYEE HEALTH PLAN 2018 form 5500 responses
2018-01-01Type of plan entitySingle employer plan
2018-01-01Plan funding arrangement – InsuranceYes
2018-01-01Plan funding arrangement – General assets of the sponsorYes
2018-01-01Plan benefit arrangement – InsuranceYes
2018-01-01Plan benefit arrangement – General assets of the sponsorYes
2017: FIESTA MART, INC. EMPLOYEE HEALTH PLAN 2017 form 5500 responses
2017-01-01Type of plan entitySingle employer plan
2017-01-01Plan funding arrangement – InsuranceYes
2017-01-01Plan funding arrangement – General assets of the sponsorYes
2017-01-01Plan benefit arrangement – InsuranceYes
2017-01-01Plan benefit arrangement – General assets of the sponsorYes
2016: FIESTA MART, INC. EMPLOYEE HEALTH PLAN 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 funding arrangement – General assets of the sponsorYes
2016-01-01Plan benefit arrangement – InsuranceYes
2016-01-01Plan benefit arrangement – General assets of the sponsorYes
2015: FIESTA MART, INC. EMPLOYEE HEALTH PLAN 2015 form 5500 responses
2015-01-01Type of plan entitySingle employer plan
2015-01-01Submission has been amendedNo
2015-01-01This submission is the final filingNo
2015-01-01This return/report is a short plan year return/report (less than 12 months)No
2015-01-01Plan is a collectively bargained planNo
2015-01-01Plan funding arrangement – InsuranceYes
2015-01-01Plan funding arrangement – General assets of the sponsorYes
2015-01-01Plan benefit arrangement – InsuranceYes
2015-01-01Plan benefit arrangement – General assets of the sponsorYes
2014: FIESTA MART, INC. EMPLOYEE HEALTH PLAN 2014 form 5500 responses
2014-01-01Type of plan entitySingle employer plan
2014-01-01Submission has been amendedNo
2014-01-01This submission is the final filingNo
2014-01-01This return/report is a short plan year return/report (less than 12 months)No
2014-01-01Plan is a collectively bargained planNo
2014-01-01Plan funding arrangement – InsuranceYes
2014-01-01Plan funding arrangement – General assets of the sponsorYes
2014-01-01Plan benefit arrangement – InsuranceYes
2014-01-01Plan benefit arrangement – General assets of the sponsorYes
2013: FIESTA MART, INC. EMPLOYEE HEALTH PLAN 2013 form 5500 responses
2013-01-01Type of plan entitySingle employer plan
2013-01-01Submission has been amendedNo
2013-01-01This submission is the final filingNo
2013-01-01This return/report is a short plan year return/report (less than 12 months)No
2013-01-01Plan is a collectively bargained planNo
2013-01-01Plan funding arrangement – InsuranceYes
2013-01-01Plan funding arrangement – General assets of the sponsorYes
2013-01-01Plan benefit arrangement – InsuranceYes
2013-01-01Plan benefit arrangement – General assets of the sponsorYes
2012: FIESTA MART, INC. EMPLOYEE HEALTH PLAN 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)No
2012-01-01Plan is a collectively bargained planNo
2012-01-01Plan funding arrangement – InsuranceYes
2012-01-01Plan funding arrangement – General assets of the sponsorYes
2012-01-01Plan benefit arrangement – InsuranceYes
2012-01-01Plan benefit arrangement – General assets of the sponsorYes
2011: FIESTA MART, INC. EMPLOYEE HEALTH PLAN 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 funding arrangement – General assets of the sponsorYes
2011-01-01Plan benefit arrangement – InsuranceYes
2011-01-01Plan benefit arrangement – General assets of the sponsorYes
2010: FIESTA MART, INC. EMPLOYEE HEALTH PLAN 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 funding arrangement – General assets of the sponsorYes
2010-01-01Plan benefit arrangement – InsuranceYes
2010-01-01Plan benefit arrangement – General assets of the sponsorYes
2009: FIESTA MART, INC. EMPLOYEE HEALTH PLAN 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 funding arrangement – General assets of the sponsorYes
2009-01-01Plan benefit arrangement – InsuranceYes
2009-01-01Plan benefit arrangement – General assets of the sponsorYes

Insurance Providers Used on plan

ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 )
Policy contract number282473
Policy instance 1
Insurance contract or identification number282473
Number of Individuals Covered2206
Insurance policy start date2021-10-01
Insurance policy end date2022-09-30
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $110,046
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 )
Policy contract number282473
Policy instance 1
Insurance contract or identification number282473
Number of Individuals Covered2676
Insurance policy start date2020-10-01
Insurance policy end date2021-09-30
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $117,533
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 )
Policy contract number282473
Policy instance 1
Insurance contract or identification number282473
Number of Individuals Covered3118
Insurance policy start date2019-10-01
Insurance policy end date2020-09-30
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $118,599
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
GERBER LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70939 )
Policy contract number2529
Policy instance 1
Insurance contract or identification number2529
Number of Individuals Covered3533
Insurance policy start date2019-01-01
Insurance policy end date2019-09-30
Total amount of commissions paid to insurance brokerUSD $5,953
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $119,060
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,953
Amount paid for insurance broker fees0
Insurance broker organization code?3
GERBER LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70939 )
Policy contract number2529
Policy instance 1
Insurance contract or identification number2529
Number of Individuals Covered3844
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $9,213
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $184,251
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,198
Amount paid for insurance broker fees0
Insurance broker organization code?3
NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 )
Policy contract number31228
Policy instance 1
Insurance contract or identification number31228
Number of Individuals Covered4691
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $14,250
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $283,891
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $14,250
Amount paid for insurance broker fees0
Insurance broker organization code?3
Insurance broker nameBROWN AND BROWN METRO, INC.
NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 )
Policy contract number31228
Policy instance 1
Insurance contract or identification number31228
Number of Individuals Covered4318
Insurance policy start date2015-01-01
Insurance policy end date2015-12-31
Total amount of commissions paid to insurance brokerUSD $15,618
Total amount of fees paid to insurance companyUSD $0
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 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 $266,154
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $8,373
Insurance broker organization code?3
Insurance broker nameBROWN AND BROWN OF NJ, INC.
NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 )
Policy contract number31228
Policy instance 1
Insurance contract or identification number31228
Number of Individuals Covered3955
Insurance policy start date2014-01-01
Insurance policy end date2014-12-31
Total amount of commissions paid to insurance brokerUSD $12,111
Total amount of fees paid to insurance companyUSD $0
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 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 $244,628
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $12,111
Insurance broker organization code?3
Insurance broker nameAMERICANIZED BENEFIT CONSULTANTS
BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )
Policy contract number93786
Policy instance 2
Insurance contract or identification number93786
Number of Individuals Covered5911
Insurance policy start date2014-01-01
Insurance policy end date2014-12-31
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $12,000
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 BenefitYes
Dental Insurance Welfare BenefitYes
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $0
Amount paid for insurance broker fees12000
Additional information about fees paid to insurance brokerSPECIAL PROGRAMS
Insurance broker organization code?3
Insurance broker nameAMERICANIZED BENEFIT CONSULTANTS
BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )
Policy contract number93786
Policy instance 2
Insurance contract or identification number93786
Number of Individuals Covered5514
Insurance policy start date2013-01-01
Insurance policy end date2013-12-31
Total amount of commissions paid to insurance brokerUSD $45,000
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Commission paid to Insurance BrokerUSD $45,000
Insurance broker organization code?3
Insurance broker nameAMERICANIZED BENEFITS CONSULTANTS,
HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93440 )
Policy contract numberX75-001
Policy instance 1
Insurance contract or identification numberX75-001
Number of Individuals Covered3816
Insurance policy start date2013-01-01
Insurance policy end date2013-12-31
Total amount of commissions paid to insurance brokerUSD $17,397
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $173,971
Commission paid to Insurance BrokerUSD $17,397
Insurance broker organization code?3
Insurance broker nameAMERICAN BENEFIT CONSULTANTS
HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93440 )
Policy contract numberX75-001
Policy instance 1
Insurance contract or identification numberX75-001
Number of Individuals Covered3572
Insurance policy start date2012-01-01
Insurance policy end date2012-12-31
Total amount of commissions paid to insurance brokerUSD $16,840
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $168,401
Commission paid to Insurance BrokerUSD $16,840
Insurance broker organization code?3
Insurance broker nameAMERICANIZED BENEFIT CONSULTANTS
BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )
Policy contract number93786
Policy instance 2
Insurance contract or identification number93786
Number of Individuals Covered5660
Insurance policy start date2012-01-01
Insurance policy end date2012-12-31
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93440 )
Policy contract numberX75
Policy instance 3
Insurance contract or identification numberX75
Number of Individuals Covered3156
Insurance policy start date2011-01-01
Insurance policy end date2011-12-31
Total amount of commissions paid to insurance brokerUSD $14,828
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $148,282
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number10109859
Policy instance 2
Insurance contract or identification number10109859
Number of Individuals Covered3043
Insurance policy start date2011-01-01
Insurance policy end date2011-12-31
Total amount of commissions paid to insurance brokerUSD $49,569
Total amount of fees paid to insurance companyUSD $6,171
Life Insurance Welfare BenefitYes
Other welfare benefits providedAD&D; DEPENDENT LIFE; OPTIONAL AD&D; OPTIONAL LIFE
Welfare Benefit Premiums Paid to CarrierUSD $495,695
AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )
Policy contract number308857
Policy instance 1
Insurance contract or identification number308857
Number of Individuals Covered6405
Insurance policy start date2011-01-01
Insurance policy end date2011-12-31
Total amount of commissions paid to insurance brokerUSD $82,956
Total amount of fees paid to insurance companyUSD $0
Welfare Benefit Premiums Paid to CarrierUSD $470,088
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number10109859
Policy instance 1
Insurance contract or identification number10109859
Number of Individuals Covered3074
Insurance policy start date2010-01-01
Insurance policy end date2010-12-31
Total amount of commissions paid to insurance brokerUSD $46,777
Total amount of fees paid to insurance companyUSD $0
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 BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH & DISMEMBERMENT
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 $467,772
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $46,777
Insurance broker organization code?3
Insurance broker nameHRH OF HOUSTON

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