SAM LEMAN I, LLC has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan SAM LEMAN - PEORIA CAFETERIA PLAN
| Measure | Date | Value |
|---|
| 2022: SAM LEMAN - PEORIA CAFETERIA PLAN 2022 401k membership |
|---|
| Total participants, beginning-of-year | 2022-08-01 | 346 |
| Total number of active participants reported on line 7a of the Form 5500 | 2022-08-01 | 393 |
| Number of retired or separated participants receiving benefits | 2022-08-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2022-08-01 | 0 |
| Total of all active and inactive participants | 2022-08-01 | 393 |
| Number of employers contributing to the scheme | 2022-08-01 | 0 |
| 2021: SAM LEMAN - PEORIA CAFETERIA PLAN 2021 401k membership |
|---|
| Total participants, beginning-of-year | 2021-08-01 | 263 |
| Total number of active participants reported on line 7a of the Form 5500 | 2021-08-01 | 346 |
| Number of retired or separated participants receiving benefits | 2021-08-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2021-08-01 | 0 |
| Total of all active and inactive participants | 2021-08-01 | 346 |
| Number of employers contributing to the scheme | 2021-08-01 | 0 |
| 2020: SAM LEMAN - PEORIA CAFETERIA PLAN 2020 401k membership |
|---|
| Total participants, beginning-of-year | 2020-08-01 | 251 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-08-01 | 263 |
| Number of retired or separated participants receiving benefits | 2020-08-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2020-08-01 | 0 |
| Total of all active and inactive participants | 2020-08-01 | 263 |
| Number of employers contributing to the scheme | 2020-08-01 | 0 |
| 2019: SAM LEMAN - PEORIA CAFETERIA PLAN 2019 401k membership |
|---|
| Total participants, beginning-of-year | 2019-08-01 | 406 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-08-01 | 388 |
| Number of retired or separated participants receiving benefits | 2019-08-01 | 2 |
| Number of other retired or separated participants entitled to future benefits | 2019-08-01 | 0 |
| Total of all active and inactive participants | 2019-08-01 | 390 |
| 2018: SAM LEMAN - PEORIA CAFETERIA PLAN 2018 401k membership |
|---|
| Total participants, beginning-of-year | 2018-08-01 | 413 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-08-01 | 392 |
| Number of retired or separated participants receiving benefits | 2018-08-01 | 3 |
| Number of other retired or separated participants entitled to future benefits | 2018-08-01 | 0 |
| Total of all active and inactive participants | 2018-08-01 | 395 |
| 2017: SAM LEMAN - PEORIA CAFETERIA PLAN 2017 401k membership |
|---|
| Total participants, beginning-of-year | 2017-08-01 | 347 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-08-01 | 404 |
| Number of retired or separated participants receiving benefits | 2017-08-01 | 4 |
| Number of other retired or separated participants entitled to future benefits | 2017-08-01 | 0 |
| Total of all active and inactive participants | 2017-08-01 | 408 |
| 2016: SAM LEMAN - PEORIA CAFETERIA PLAN 2016 401k membership |
|---|
| Total participants, beginning-of-year | 2016-08-01 | 375 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-08-01 | 370 |
| Number of retired or separated participants receiving benefits | 2016-08-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2016-08-01 | 0 |
| Total of all active and inactive participants | 2016-08-01 | 370 |
| 2015: SAM LEMAN - PEORIA CAFETERIA PLAN 2015 401k membership |
|---|
| Total participants, beginning-of-year | 2015-08-01 | 288 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-08-01 | 312 |
| Number of retired or separated participants receiving benefits | 2015-08-01 | 1 |
| Number of other retired or separated participants entitled to future benefits | 2015-08-01 | 0 |
| Total of all active and inactive participants | 2015-08-01 | 313 |
| Total participants, beginning-of-year | 2015-05-01 | 297 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-05-01 | 271 |
| Number of retired or separated participants receiving benefits | 2015-05-01 | 3 |
| Number of other retired or separated participants entitled to future benefits | 2015-05-01 | 0 |
| Total of all active and inactive participants | 2015-05-01 | 274 |
| 2014: SAM LEMAN - PEORIA CAFETERIA PLAN 2014 401k membership |
|---|
| Total participants, beginning-of-year | 2014-05-01 | 278 |
| Total number of active participants reported on line 7a of the Form 5500 | 2014-05-01 | 286 |
| Number of retired or separated participants receiving benefits | 2014-05-01 | 2 |
| Number of other retired or separated participants entitled to future benefits | 2014-05-01 | 0 |
| Total of all active and inactive participants | 2014-05-01 | 288 |
| 2013: SAM LEMAN - PEORIA CAFETERIA PLAN 2013 401k membership |
|---|
| Total participants, beginning-of-year | 2013-05-01 | 271 |
| Total number of active participants reported on line 7a of the Form 5500 | 2013-05-01 | 212 |
| Number of retired or separated participants receiving benefits | 2013-05-01 | 1 |
| Total of all active and inactive participants | 2013-05-01 | 213 |
| 2012: SAM LEMAN - PEORIA CAFETERIA PLAN 2012 401k membership |
|---|
| Total participants, beginning-of-year | 2012-05-01 | 195 |
| Total number of active participants reported on line 7a of the Form 5500 | 2012-05-01 | 271 |
| Number of retired or separated participants receiving benefits | 2012-05-01 | 2 |
| Total of all active and inactive participants | 2012-05-01 | 273 |
| 2011: SAM LEMAN - PEORIA CAFETERIA PLAN 2011 401k membership |
|---|
| Total participants, beginning-of-year | 2011-05-01 | 202 |
| Total number of active participants reported on line 7a of the Form 5500 | 2011-05-01 | 195 |
| Number of retired or separated participants receiving benefits | 2011-05-01 | 1 |
| Total of all active and inactive participants | 2011-05-01 | 196 |
| 2009: SAM LEMAN - PEORIA CAFETERIA PLAN 2009 401k membership |
|---|
| Total participants, beginning-of-year | 2009-05-01 | 193 |
| Total number of active participants reported on line 7a of the Form 5500 | 2009-05-01 | 195 |
| Number of retired or separated participants receiving benefits | 2009-05-01 | 0 |
| Total of all active and inactive participants | 2009-05-01 | 195 |
| 2022: SAM LEMAN - PEORIA CAFETERIA PLAN 2022 form 5500 responses |
|---|
| 2022-08-01 | Type of plan entity | Single employer plan |
| 2022-08-01 | Plan funding arrangement – Insurance | Yes |
| 2022-08-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2022-08-01 | Plan benefit arrangement – Insurance | Yes |
| 2022-08-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2021: SAM LEMAN - PEORIA CAFETERIA PLAN 2021 form 5500 responses |
|---|
| 2021-08-01 | Type of plan entity | Single employer plan |
| 2021-08-01 | Plan funding arrangement – Insurance | Yes |
| 2021-08-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2021-08-01 | Plan benefit arrangement – Insurance | Yes |
| 2021-08-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2020: SAM LEMAN - PEORIA CAFETERIA PLAN 2020 form 5500 responses |
|---|
| 2020-08-01 | Type of plan entity | Single employer plan |
| 2020-08-01 | Plan funding arrangement – Insurance | Yes |
| 2020-08-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2020-08-01 | Plan benefit arrangement – Insurance | Yes |
| 2020-08-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2019: SAM LEMAN - PEORIA CAFETERIA PLAN 2019 form 5500 responses |
|---|
| 2019-08-01 | Type of plan entity | Single employer plan |
| 2019-08-01 | Submission has been amended | No |
| 2019-08-01 | This submission is the final filing | No |
| 2019-08-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2019-08-01 | Plan is a collectively bargained plan | No |
| 2019-08-01 | Plan funding arrangement – Insurance | Yes |
| 2019-08-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2019-08-01 | Plan benefit arrangement – Insurance | Yes |
| 2019-08-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2018: SAM LEMAN - PEORIA CAFETERIA PLAN 2018 form 5500 responses |
|---|
| 2018-08-01 | Type of plan entity | Single employer plan |
| 2018-08-01 | Submission has been amended | No |
| 2018-08-01 | This submission is the final filing | No |
| 2018-08-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2018-08-01 | Plan is a collectively bargained plan | No |
| 2018-08-01 | Plan funding arrangement – Insurance | Yes |
| 2018-08-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2018-08-01 | Plan benefit arrangement – Insurance | Yes |
| 2018-08-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2017: SAM LEMAN - PEORIA CAFETERIA PLAN 2017 form 5500 responses |
|---|
| 2017-08-01 | Type of plan entity | Single employer plan |
| 2017-08-01 | Submission has been amended | No |
| 2017-08-01 | This submission is the final filing | No |
| 2017-08-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2017-08-01 | Plan is a collectively bargained plan | No |
| 2017-08-01 | Plan funding arrangement – Insurance | Yes |
| 2017-08-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2017-08-01 | Plan benefit arrangement – Insurance | Yes |
| 2017-08-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2016: SAM LEMAN - PEORIA CAFETERIA PLAN 2016 form 5500 responses |
|---|
| 2016-08-01 | Type of plan entity | Single employer plan |
| 2016-08-01 | Submission has been amended | No |
| 2016-08-01 | This submission is the final filing | No |
| 2016-08-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2016-08-01 | Plan is a collectively bargained plan | No |
| 2016-08-01 | Plan funding arrangement – Insurance | Yes |
| 2016-08-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2016-08-01 | Plan benefit arrangement – Insurance | Yes |
| 2016-08-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2015: SAM LEMAN - PEORIA CAFETERIA PLAN 2015 form 5500 responses |
|---|
| 2015-08-01 | Type of plan entity | Single employer plan |
| 2015-08-01 | Submission has been amended | No |
| 2015-08-01 | This submission is the final filing | No |
| 2015-08-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2015-08-01 | Plan is a collectively bargained plan | No |
| 2015-08-01 | Plan funding arrangement – Insurance | Yes |
| 2015-08-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2015-08-01 | Plan benefit arrangement – Insurance | Yes |
| 2015-08-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2015-05-01 | Type of plan entity | Single employer plan |
| 2015-05-01 | Submission has been amended | No |
| 2015-05-01 | This submission is the final filing | No |
| 2015-05-01 | This return/report is a short plan year return/report (less than 12 months) | Yes |
| 2015-05-01 | Plan is a collectively bargained plan | No |
| 2015-05-01 | Plan funding arrangement – Insurance | Yes |
| 2015-05-01 | Plan benefit arrangement – Insurance | Yes |
| 2014: SAM LEMAN - PEORIA CAFETERIA PLAN 2014 form 5500 responses |
|---|
| 2014-05-01 | Type of plan entity | Single employer plan |
| 2014-05-01 | Submission has been amended | No |
| 2014-05-01 | This submission is the final filing | No |
| 2014-05-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2014-05-01 | Plan is a collectively bargained plan | No |
| 2014-05-01 | Plan funding arrangement – Insurance | Yes |
| 2014-05-01 | Plan benefit arrangement – Insurance | Yes |
| 2013: SAM LEMAN - PEORIA CAFETERIA PLAN 2013 form 5500 responses |
|---|
| 2013-05-01 | Type of plan entity | Single employer plan |
| 2013-05-01 | Plan funding arrangement – Insurance | Yes |
| 2013-05-01 | Plan benefit arrangement – Insurance | Yes |
| 2012: SAM LEMAN - PEORIA CAFETERIA PLAN 2012 form 5500 responses |
|---|
| 2012-05-01 | Type of plan entity | Single employer plan |
| 2012-05-01 | Plan funding arrangement – Insurance | Yes |
| 2012-05-01 | Plan benefit arrangement – Insurance | Yes |
| 2011: SAM LEMAN - PEORIA CAFETERIA PLAN 2011 form 5500 responses |
|---|
| 2011-05-01 | Type of plan entity | Single employer plan |
| 2011-05-01 | Plan funding arrangement – Insurance | Yes |
| 2011-05-01 | Plan benefit arrangement – Insurance | Yes |
| 2009: SAM LEMAN - PEORIA CAFETERIA PLAN 2009 form 5500 responses |
|---|
| 2009-05-01 | Type of plan entity | Single employer plan |
| 2009-05-01 | Plan funding arrangement – Insurance | Yes |
| 2009-05-01 | Plan benefit arrangement – Insurance | Yes |
| BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 ) |
| Policy contract number | 138392 |
| Policy instance | 3 |
| Insurance contract or identification number | 138392 | | Number of Individuals Covered | 397 | | Insurance policy start date | 2022-08-01 | | Insurance policy end date | 2023-07-31 | | Total amount of commissions paid to insurance broker | USD $6,445 | | Total amount of fees paid to insurance company | USD $10,789 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $129,076 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $6,445 | | Amount paid for insurance broker fees | 2290 | | Additional information about fees paid to insurance broker | SPECIAL PROGRAMS | | Insurance broker organization code? | 3 |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 12516 ) |
| Policy contract number | 30099566 |
| Policy instance | 2 |
| Insurance contract or identification number | 30099566 | | Number of Individuals Covered | 172 | | Insurance policy start date | 2022-08-01 | | Insurance policy end date | 2023-07-31 | | Total amount of commissions paid to insurance broker | USD $1,753 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $17,311 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,753 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 ) |
| Policy contract number | F017360 |
| Policy instance | 1 |
| Insurance contract or identification number | F017360 | | Number of Individuals Covered | 393 | | Insurance policy start date | 2022-08-01 | | Insurance policy end date | 2023-07-31 | | Total amount of commissions paid to insurance broker | USD $30,814 | | Total amount of fees paid to insurance company | USD $3,945 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $202,244 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $30,814 | | Amount paid for insurance broker fees | 3945 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | | Insurance broker organization code? | 3 |
|
| DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 ) |
| Policy contract number | F017360 |
| Policy instance | 1 |
| Insurance contract or identification number | F017360 | | Number of Individuals Covered | 346 | | Insurance policy start date | 2021-08-01 | | Insurance policy end date | 2022-07-31 | | Total amount of commissions paid to insurance broker | USD $27,562 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $179,791 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $27,562 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 12516 ) |
| Policy contract number | 30099566 |
| Policy instance | 2 |
| Insurance contract or identification number | 30099566 | | Number of Individuals Covered | 152 | | Insurance policy start date | 2021-08-01 | | Insurance policy end date | 2022-07-31 | | Total amount of commissions paid to insurance broker | USD $1,424 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $14,506 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,424 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 ) |
| Policy contract number | 138392 |
| Policy instance | 3 |
| Insurance contract or identification number | 138392 | | Number of Individuals Covered | 366 | | Insurance policy start date | 2021-08-01 | | Insurance policy end date | 2022-07-31 | | Total amount of commissions paid to insurance broker | USD $6,425 | | Total amount of fees paid to insurance company | USD $4,942 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $128,005 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | Yes | | Commission paid to Insurance Broker | USD $6,425 | | Amount paid for insurance broker fees | 1834 | | Additional information about fees paid to insurance broker | SPECIAL PROGRAMS | | Insurance broker organization code? | 3 |
|
| PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 ) |
| Policy contract number | 1095959 |
| Policy instance | 2 |
| Insurance contract or identification number | 1095959 | | Number of Individuals Covered | 354 | | Insurance policy start date | 2020-08-01 | | Insurance policy end date | 2021-07-31 | | Total amount of commissions paid to insurance broker | USD $5,046 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $121,098 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,046 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 ) |
| Policy contract number | F017360 |
| Policy instance | 1 |
| Insurance contract or identification number | F017360 | | Number of Individuals Covered | 404 | | Insurance policy start date | 2020-08-01 | | Insurance policy end date | 2021-07-31 | | Total amount of commissions paid to insurance broker | USD $22,272 | | Total amount of fees paid to insurance company | USD $3,538 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ACCIDENTAL DEATH AND DISMEMBERMENT | | Welfare Benefit Premiums Paid to Carrier | USD $143,183 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $22,272 | | Amount paid for insurance broker fees | 3538 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | | Insurance broker organization code? | 3 |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 12516 ) |
| Policy contract number | 30099566 |
| Policy instance | 3 |
| Insurance contract or identification number | 30099566 | | Number of Individuals Covered | 115 | | Insurance policy start date | 2020-08-01 | | Insurance policy end date | 2021-07-31 | | Total amount of commissions paid to insurance broker | USD $1,032 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $10,271 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,032 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 ) |
| Policy contract number | 1095959 |
| Policy instance | 2 |
| Insurance contract or identification number | 1095959 | | Number of Individuals Covered | 336 | | Insurance policy start date | 2019-08-01 | | Insurance policy end date | 2020-07-31 | | Total amount of commissions paid to insurance broker | USD $4,727 | | Total amount of fees paid to insurance company | USD $486 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | 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 Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | 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 Carrier | USD $112,878 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,727 | | Amount paid for insurance broker fees | 486 | | Additional information about fees paid to insurance broker | BONUS | | Insurance broker organization code? | 3 |
|
| DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 ) |
| Policy contract number | F017360 |
| Policy instance | 1 |
| Insurance contract or identification number | F017360 | | Number of Individuals Covered | 400 | | Insurance policy start date | 2019-08-01 | | Insurance policy end date | 2020-07-31 | | Total amount of commissions paid to insurance broker | USD $20,139 | | Total amount of fees paid to insurance company | USD $8,194 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | 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 Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | AD&D | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $128,621 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $20,139 | | Amount paid for insurance broker fees | 8194 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | | Insurance broker organization code? | 3 |
|
| BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 ) |
| Policy contract number | 138392 |
| Policy instance | 3 |
| Insurance contract or identification number | 138392 | | Number of Individuals Covered | 322 | | Insurance policy start date | 2019-08-01 | | Insurance policy end date | 2020-07-31 | | Total amount of commissions paid to insurance broker | USD $27,117 | | Total amount of fees paid to insurance company | USD $3,315 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | 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 Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | 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 Carrier | USD $389,577 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $27,117 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 3315 | | Additional information about fees paid to insurance broker | SPECIAL PROGRAMS |
|
| DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 ) |
| Policy contract number | F017360 |
| Policy instance | 1 |
| Insurance contract or identification number | F017360 | | Number of Individuals Covered | 393 | | Insurance policy start date | 2018-08-01 | | Insurance policy end date | 2019-07-31 | | Total amount of commissions paid to insurance broker | USD $18,411 | | Total amount of fees paid to insurance company | USD $5,592 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | 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 Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | AD&D | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $121,322 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $18,411 | | Amount paid for insurance broker fees | 5592 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | | Insurance broker organization code? | 3 |
|
| PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 ) |
| Policy contract number | 1095959 |
| Policy instance | 2 |
| Insurance contract or identification number | 1095959 | | Number of Individuals Covered | 331 | | Insurance policy start date | 2018-08-01 | | Insurance policy end date | 2019-07-31 | | Total amount of commissions paid to insurance broker | USD $4,969 | | Total amount of fees paid to insurance company | USD $8,466 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | 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 Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | 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 Carrier | USD $119,861 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,969 | | Amount paid for insurance broker fees | 8466 | | Additional information about fees paid to insurance broker | BONUS | | Insurance broker organization code? | 3 |
|
| DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 ) |
| Policy contract number | F017360 |
| Policy instance | 1 |
| Insurance contract or identification number | F017360 | | Number of Individuals Covered | 407 | | Insurance policy start date | 2017-08-01 | | Insurance policy end date | 2018-07-31 | | Total amount of commissions paid to insurance broker | USD $18,135 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | 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 Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | AD&D | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $115,321 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 ) |
| Policy contract number | 188186 |
| Policy instance | 2 |
| Insurance contract or identification number | 188186 | | Number of Individuals Covered | 330 | | Insurance policy start date | 2017-08-01 | | Insurance policy end date | 2018-07-31 | | Total amount of commissions paid to insurance broker | USD $5,784 | | Total amount of fees paid to insurance company | USD $0 | | Are there contracts with allocated funds for individual policies? | 0 | | Are there contracts with allocated funds for group deferred annuity? | No | | Are there contracts with allocated funds for types other than group deferred annuity or individual? | No | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | 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 Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | 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 Carrier | USD $115,944 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 ) |
| Policy contract number | 1037193 |
| Policy instance | 2 |
| Insurance contract or identification number | 1037193 | | Number of Individuals Covered | 424 | | Insurance policy start date | 2015-08-01 | | Insurance policy end date | 2016-07-31 | | Total amount of commissions paid to insurance broker | USD $9,916 | | Total amount of fees paid to insurance company | USD $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 plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | 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 Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | 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 Carrier | USD $136,373 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $9,916 | | Insurance broker organization code? | 3 | | Insurance broker name | CLEMENS & ASSOC LIFE AGENCY LTD |
|
| DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 ) |
| Policy contract number | F017360 |
| Policy instance | 1 |
| Insurance contract or identification number | F017360 | | Number of Individuals Covered | 95 | | Insurance policy start date | 2015-08-01 | | Insurance policy end date | 2016-07-31 | | Total amount of commissions paid to insurance broker | USD $9,363 | | Total amount of fees paid to insurance company | USD $2,415 | | 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 plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | 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 Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | 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 Carrier | USD $56,611 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $9,363 | | Amount paid for insurance broker fees | 2415 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | CLEMENS & ASSOCIATES LIFE AGENCY LT |
|
| PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 ) |
| Policy contract number | 1037193 |
| Policy instance | 1 |
| Insurance contract or identification number | 1037193 | | Number of Individuals Covered | 411 | | Insurance policy start date | 2014-08-01 | | Insurance policy end date | 2015-07-31 | | Total amount of commissions paid to insurance broker | USD $9,462 | | Total amount of fees paid to insurance company | USD $1,540 | | 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 plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | 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 Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | 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 Carrier | USD $127,779 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $9,462 | | Amount paid for insurance broker fees | 1540 | | Additional information about fees paid to insurance broker | BONUS | | Insurance broker organization code? | 3 | | Insurance broker name | CLEMENS & ASSOC LIFE AGENCY LTD |
|
| DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 ) |
| Policy contract number | F017360 |
| Policy instance | 3 |
| Insurance contract or identification number | F017360 | | Number of Individuals Covered | 87 | | Insurance policy start date | 2014-08-01 | | Insurance policy end date | 2015-07-31 | | Total amount of commissions paid to insurance broker | USD $7,812 | | Total amount of fees paid to insurance company | USD $2,433 | | 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 plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | 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 Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | 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 Carrier | USD $48,757 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,812 | | Amount paid for insurance broker fees | 2433 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | CLEMENS & ASSOCIATES LIFE AGENCY LT |
|
| BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 ) |
| Policy contract number | PA1528 |
| Policy instance | 2 |
| Insurance contract or identification number | PA1528 | | Number of Individuals Covered | 261 | | Insurance policy start date | 2014-08-01 | | Insurance policy end date | 2015-07-31 | | Total amount of commissions paid to insurance broker | USD $20,367 | | Total amount of fees paid to insurance company | USD $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 plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | 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 Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | 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 Carrier | USD $172,201 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $20,367 | | Insurance broker organization code? | 3 | | Insurance broker name | CLEMENS & ASSOC LIFE AGY LTD |
|
| PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 ) |
| Policy contract number | 1037193 |
| Policy instance | 1 |
| Insurance contract or identification number | 1037193 | | Number of Individuals Covered | 419 | | Insurance policy start date | 2013-08-01 | | Insurance policy end date | 2014-07-31 | | Total amount of commissions paid to insurance broker | USD $9,178 | | Total amount of fees paid to insurance company | USD $3,725 | | 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 plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | 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 Benefit | No | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | 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 Carrier | USD $119,671 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $9,178 | | Amount paid for insurance broker fees | 3725 | | Additional information about fees paid to insurance broker | BONUS | | Insurance broker organization code? | 3 | | Insurance broker name | CLEMENS & ASSOC. LIFE AGENCY LTD |
|
| HUMANA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 73288 ) |
| Policy contract number | 566182 |
| Policy instance | 2 |
| Insurance contract or identification number | 566182 | | Number of Individuals Covered | 171 | | Insurance policy start date | 2013-08-01 | | Insurance policy end date | 2014-07-31 | | Total amount of commissions paid to insurance broker | USD $21,510 | | Total amount of fees paid to insurance company | USD $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 plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | 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 Benefit | Yes | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | 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 Carrier | USD $1,082,581 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $21,510 | | Insurance broker organization code? | 3 | | Insurance broker name | CLEMENS & ASSOC LIFE AGY LTD |
|
| DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 ) |
| Policy contract number | F017360 |
| Policy instance | 3 |
| Insurance contract or identification number | F017360 | | Number of Individuals Covered | 74 | | Insurance policy start date | 2013-08-01 | | Insurance policy end date | 2014-07-31 | | Total amount of commissions paid to insurance broker | USD $6,871 | | Total amount of fees paid to insurance company | USD $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 plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | 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 Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | No | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Unemployment Insurance Welfare Benefit | No | | 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 Carrier | USD $43,322 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,871 | | Insurance broker organization code? | 3 | | Insurance broker name | CLEMENS & ASSOCIATES LIFE AGENCY LT |
|
| DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 ) |
| Policy contract number | F017360 |
| Policy instance | 1 |
| Insurance contract or identification number | F017360 | | Number of Individuals Covered | 73 | | Insurance policy start date | 2012-08-01 | | Insurance policy end date | 2013-07-31 | | Total amount of commissions paid to insurance broker | USD $18,308 | | Dental Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $149,644 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $18,308 | | Insurance broker organization code? | 3 | | Insurance broker name | CLEMENS & ASSOC. LIFE AGENCY, INC. |
|
| HUMANA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 73288 ) |
| Policy contract number | 566182 |
| Policy instance | 2 |
| Insurance contract or identification number | 566182 | | Number of Individuals Covered | 158 | | Insurance policy start date | 2012-08-01 | | Insurance policy end date | 2013-07-31 | | Total amount of commissions paid to insurance broker | USD $28,248 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $996,557 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $28,248 | | Insurance broker organization code? | 3 | | Insurance broker name | CLEMENS & ASSOC LIFE AGY LTD |
|
| DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 ) |
| Policy contract number | F017360 |
| Policy instance | 1 |
| Insurance contract or identification number | F017360 | | Number of Individuals Covered | 68 | | Insurance policy start date | 2011-08-01 | | Insurance policy end date | 2012-07-31 | | Total amount of commissions paid to insurance broker | USD $17,237 | | Dental Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $139,491 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $17,237 | | Insurance broker organization code? | 3 | | Insurance broker name | CLEMENS & ASSOC. LIFE AGENCY, INC. |
|
| HUMANA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 73288 ) |
| Policy contract number | 566182 |
| Policy instance | 2 |
| Insurance contract or identification number | 566182 | | Number of Individuals Covered | 151 | | Insurance policy start date | 2011-08-01 | | Insurance policy end date | 2012-07-31 | | Total amount of commissions paid to insurance broker | USD $34,357 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $853,462 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $18,238 | | Insurance broker organization code? | 3 | | Insurance broker name | ROGERS BENEFIT GROUP INC |
|
| DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 ) |
| Policy contract number | F017360-0 |
| Policy instance | 1 |
| Insurance contract or identification number | F017360-0 | | Number of Individuals Covered | 251 | | Insurance policy start date | 2010-08-01 | | Insurance policy end date | 2011-07-31 | | Total amount of commissions paid to insurance broker | USD $15,739 | | Dental Insurance Welfare Benefit | Yes | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $126,228 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| HUMANA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 73288 ) |
| Policy contract number | 566182 |
| Policy instance | 2 |
| Insurance contract or identification number | 566182 | | Number of Individuals Covered | 156 | | Insurance policy start date | 2010-08-01 | | Insurance policy end date | 2011-07-31 | | Total amount of commissions paid to insurance broker | USD $16,333 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $821,382 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 ) |
| Policy contract number | FD17360-0 |
| Policy instance | 3 |
| Insurance contract or identification number | FD17360-0 | | Number of Individuals Covered | 57 | | Insurance policy start date | 2009-08-01 | | Insurance policy end date | 2010-07-31 | | Total amount of commissions paid to insurance broker | USD $6,903 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $35,919 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 ) |
| Policy contract number | P89564 |
| Policy instance | 2 |
| Insurance contract or identification number | P89564 | | Number of Individuals Covered | 240 | | Insurance policy start date | 2009-08-01 | | Insurance policy end date | 2010-07-31 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $832,699 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 714897 |
| Policy instance | 1 |
| Insurance contract or identification number | 714897 | | Number of Individuals Covered | 284 | | Insurance policy start date | 2009-08-01 | | Insurance policy end date | 2010-07-31 | | Total amount of commissions paid to insurance broker | USD $3,393 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $53,439 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
