SHACKELFORD COUNTY COMMUNITY HEALTH CENTER has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan SHACKELFORD COUNTY COMMUNITY HEALTH AND WELFARE PLAN
| 2023: SHACKELFORD COUNTY COMMUNITY HEALTH AND WELFARE PLAN 2023 form 5500 responses |
|---|
| 2023-03-01 | Type of plan entity | Single employer plan |
| 2023-03-01 | Submission has been amended | No |
| 2023-03-01 | This submission is the final filing | No |
| 2023-03-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2023-03-01 | Plan is a collectively bargained plan | No |
| 2023-03-01 | Plan funding arrangement – Insurance | Yes |
| 2023-03-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2023-03-01 | Plan benefit arrangement – Insurance | Yes |
| 2023-03-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2022: SHACKELFORD COUNTY COMMUNITY HEALTH AND WELFARE PLAN 2022 form 5500 responses |
|---|
| 2022-03-01 | Type of plan entity | Single employer plan |
| 2022-03-01 | Submission has been amended | No |
| 2022-03-01 | This submission is the final filing | No |
| 2022-03-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2022-03-01 | Plan is a collectively bargained plan | No |
| 2022-03-01 | Plan funding arrangement – Insurance | Yes |
| 2022-03-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2022-03-01 | Plan benefit arrangement – Insurance | Yes |
| 2022-03-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2021: SHACKELFORD COUNTY COMMUNITY HEALTH AND WELFARE PLAN 2021 form 5500 responses |
|---|
| 2021-03-01 | Type of plan entity | Single employer plan |
| 2021-03-01 | Submission has been amended | No |
| 2021-03-01 | This submission is the final filing | No |
| 2021-03-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2021-03-01 | Plan is a collectively bargained plan | No |
| 2021-03-01 | Plan funding arrangement – Insurance | Yes |
| 2021-03-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2021-03-01 | Plan benefit arrangement – Insurance | Yes |
| 2021-03-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2020: SHACKELFORD COUNTY COMMUNITY HEALTH AND WELFARE PLAN 2020 form 5500 responses |
|---|
| 2020-03-01 | Type of plan entity | Single employer plan |
| 2020-03-01 | Submission has been amended | Yes |
| 2020-03-01 | This submission is the final filing | No |
| 2020-03-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2020-03-01 | Plan is a collectively bargained plan | No |
| 2020-03-01 | Plan funding arrangement – Insurance | Yes |
| 2020-03-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2020-03-01 | Plan benefit arrangement – Insurance | Yes |
| 2020-03-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2019: SHACKELFORD COUNTY COMMUNITY HEALTH AND WELFARE PLAN 2019 form 5500 responses |
|---|
| 2019-03-02 | Type of plan entity | Single employer plan |
| 2019-03-02 | Submission has been amended | No |
| 2019-03-02 | This submission is the final filing | No |
| 2019-03-02 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2019-03-02 | Plan is a collectively bargained plan | No |
| 2019-03-02 | Plan funding arrangement – Insurance | Yes |
| 2019-03-02 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2019-03-02 | Plan benefit arrangement – Insurance | Yes |
| 2019-03-02 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2019-03-01 | Type of plan entity | Single employer plan |
| 2019-03-01 | Submission has been amended | Yes |
| 2019-03-01 | This submission is the final filing | No |
| 2019-03-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2019-03-01 | Plan is a collectively bargained plan | No |
| 2019-03-01 | Plan funding arrangement – Insurance | Yes |
| 2019-03-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2019-03-01 | Plan benefit arrangement – Insurance | Yes |
| 2019-03-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2018: SHACKELFORD COUNTY COMMUNITY HEALTH AND WELFARE PLAN 2018 form 5500 responses |
|---|
| 2018-03-01 | Type of plan entity | Single employer plan |
| 2018-03-01 | First time form 5500 has been submitted | Yes |
| 2018-03-01 | Submission has been amended | No |
| 2018-03-01 | This submission is the final filing | No |
| 2018-03-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2018-03-01 | Plan is a collectively bargained plan | No |
| 2018-03-01 | Plan funding arrangement – Insurance | Yes |
| 2018-03-01 | Plan benefit arrangement – Insurance | Yes |
| 2017: SHACKELFORD COUNTY COMMUNITY HEALTH AND WELFARE PLAN 2017 form 5500 responses |
|---|
| 2017-03-01 | Type of plan entity | Single employer plan |
| 2017-03-01 | First time form 5500 has been submitted | Yes |
| 2017-03-01 | Submission has been amended | No |
| 2017-03-01 | This submission is the final filing | No |
| 2017-03-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2017-03-01 | Plan is a collectively bargained plan | No |
| 2017-03-01 | Plan funding arrangement – Insurance | Yes |
| 2017-03-01 | Plan benefit arrangement – Insurance | Yes |
| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
| Policy contract number | 5383294 |
| Policy instance | 9 |
| Insurance contract or identification number | 5383294 | | Number of Individuals Covered | 153 | | Insurance policy start date | 2023-03-01 | | Insurance policy end date | 2024-02-29 | | Total amount of commissions paid to insurance broker | USD $1,037 | | Total amount of fees paid to insurance company | USD $304 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | 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 $7,748 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AS5N |
| Policy instance | 1 |
| Insurance contract or identification number | G000AS5N | | Number of Individuals Covered | 107 | | Insurance policy start date | 2023-03-01 | | Insurance policy end date | 2024-02-29 | | Total amount of commissions paid to insurance broker | USD $326 | | Total amount of fees paid to insurance company | USD $243 | | 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 | No | | Long Term Disability Insurance Welfare Benefit | No | | 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 $2,174 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AS5N |
| Policy instance | 2 |
| Insurance contract or identification number | G000AS5N | | Number of Individuals Covered | 33 | | Insurance policy start date | 2023-03-01 | | Insurance policy end date | 2024-02-29 | | Total amount of commissions paid to insurance broker | USD $2,628 | | Total amount of fees paid to insurance company | USD $1,838 | | 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 | 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 $17,519 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AS5N |
| Policy instance | 3 |
| Insurance contract or identification number | G000AS5N | | Number of Individuals Covered | 23 | | Insurance policy start date | 2023-03-01 | | Insurance policy end date | 2024-02-29 | | Total amount of commissions paid to insurance broker | USD $1,229 | | Total amount of fees paid to insurance company | USD $1,541 | | 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 | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | CRITICAL ILLNESS | | 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 $8,194 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AS5N |
| Policy instance | 4 |
| Insurance contract or identification number | G000AS5N | | Number of Individuals Covered | 34 | | Insurance policy start date | 2023-03-01 | | Insurance policy end date | 2024-02-29 | | Total amount of commissions paid to insurance broker | USD $1,239 | | Total amount of fees paid to insurance company | USD $1,588 | | 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 | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENT | | 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 $8,259 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AS5N |
| Policy instance | 5 |
| Insurance contract or identification number | G000AS5N | | Number of Individuals Covered | 14 | | Insurance policy start date | 2023-03-01 | | Insurance policy end date | 2024-02-29 | | Total amount of commissions paid to insurance broker | USD $3,374 | | Total amount of fees paid to insurance company | USD $2,263 | | 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 | No | | 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 $22,490 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AS5N |
| Policy instance | 6 |
| Insurance contract or identification number | G000AS5N | | Number of Individuals Covered | 67 | | Insurance policy start date | 2023-03-01 | | Insurance policy end date | 2024-02-29 | | Total amount of commissions paid to insurance broker | USD $3,828 | | Total amount of fees paid to insurance company | USD $2,787 | | 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 | No | | Long Term Disability Insurance Welfare Benefit | No | | 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 $25,520 | | 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 | 339561 |
| Policy instance | 7 |
| Insurance contract or identification number | 339561 | | Number of Individuals Covered | 151 | | Insurance policy start date | 2023-03-01 | | Insurance policy end date | 2024-02-29 | | Total amount of commissions paid to insurance broker | USD $41,867 | | Total amount of fees paid to insurance company | USD $6,676 | | Health Insurance Welfare Benefit | Yes | | 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 $662,091 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AS5N |
| Policy instance | 8 |
| Insurance contract or identification number | G000AS5N | | Number of Individuals Covered | 17 | | Insurance policy start date | 2023-03-01 | | Insurance policy end date | 2024-02-29 | | Total amount of commissions paid to insurance broker | USD $1,284 | | Total amount of fees paid to insurance company | USD $321 | | 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 | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | HOSPITAL | | 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 $6,418 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AS5N |
| Policy instance | 1 |
| Insurance contract or identification number | G000AS5N | | Number of Individuals Covered | 109 | | Insurance policy start date | 2022-03-01 | | Insurance policy end date | 2023-02-28 | | Total amount of commissions paid to insurance broker | USD $333 | | Total amount of fees paid to insurance company | USD $137 | | 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 | No | | Long Term Disability Insurance Welfare Benefit | No | | 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 $2,221 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AS5N |
| Policy instance | 2 |
| Insurance contract or identification number | G000AS5N | | Number of Individuals Covered | 36 | | Insurance policy start date | 2022-03-01 | | Insurance policy end date | 2023-02-28 | | Total amount of commissions paid to insurance broker | USD $2,454 | | Total amount of fees paid to insurance company | USD $870 | | 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 | 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 $16,361 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AS5N |
| Policy instance | 3 |
| Insurance contract or identification number | G000AS5N | | Number of Individuals Covered | 24 | | Insurance policy start date | 2022-03-01 | | Insurance policy end date | 2023-02-28 | | Total amount of commissions paid to insurance broker | USD $1,199 | | Total amount of fees paid to insurance company | USD $1,193 | | 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 | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | CRITICAL ILLNESS | | 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 $7,996 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AS5N |
| Policy instance | 4 |
| Insurance contract or identification number | G000AS5N | | Number of Individuals Covered | 36 | | Insurance policy start date | 2022-03-01 | | Insurance policy end date | 2023-02-28 | | Total amount of commissions paid to insurance broker | USD $1,300 | | Total amount of fees paid to insurance company | USD $1,226 | | 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 | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | ACCIDENT | | 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 $8,667 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AS5N |
| Policy instance | 5 |
| Insurance contract or identification number | G000AS5N | | Number of Individuals Covered | 12 | | Insurance policy start date | 2022-03-01 | | Insurance policy end date | 2023-02-28 | | Total amount of commissions paid to insurance broker | USD $2,802 | | Total amount of fees paid to insurance company | USD $1,199 | | 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 | No | | 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 $18,683 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AS5N |
| Policy instance | 6 |
| Insurance contract or identification number | G000AS5N | | Number of Individuals Covered | 69 | | Insurance policy start date | 2022-03-01 | | Insurance policy end date | 2023-02-28 | | Total amount of commissions paid to insurance broker | USD $3,737 | | Total amount of fees paid to insurance company | USD $1,697 | | 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 | No | | Long Term Disability Insurance Welfare Benefit | No | | 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 $24,911 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| BLOCK VISION (National Association of Insurance Commissioners NAIC id number: 95387 ) |
| Policy contract number | 330790 |
| Policy instance | 7 |
| Insurance contract or identification number | 330790 | | Number of Individuals Covered | 90 | | Insurance policy start date | 2022-03-01 | | Insurance policy end date | 2023-02-28 | | Total amount of commissions paid to insurance broker | USD $2,238 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | No | | Dental Insurance Welfare Benefit | No | | Vision Insurance Welfare Benefit | Yes | | 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 $10,272 | | 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 | 339561 |
| Policy instance | 8 |
| Insurance contract or identification number | 339561 | | Number of Individuals Covered | 111 | | Insurance policy start date | 2022-03-01 | | Insurance policy end date | 2023-02-28 | | Total amount of commissions paid to insurance broker | USD $46,034 | | Total amount of fees paid to insurance company | USD $0 | | Health Insurance Welfare Benefit | Yes | | 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 $826,476 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| BLOCK VISION (National Association of Insurance Commissioners NAIC id number: 95387 ) |
| Policy contract number | 330790 |
| Policy instance | 8 |
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 0917217 |
| Policy instance | 7 |
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AS5N |
| Policy instance | 6 |
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AS5N |
| Policy instance | 5 |
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AS5N |
| Policy instance | 4 |
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AS5N |
| Policy instance | 3 |
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AS5N |
| Policy instance | 2 |
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AS5N |
| Policy instance | 1 |
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AS5N |
| Policy instance | 1 |
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AS5N |
| Policy instance | 2 |
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AS5N |
| Policy instance | 3 |
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AS5N |
| Policy instance | 4 |
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AS5N |
| Policy instance | 5 |
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AS5N |
| Policy instance | 6 |
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 0917217 |
| Policy instance | 7 |
| BLOCK VISION (National Association of Insurance Commissioners NAIC id number: 95387 ) |
| Policy contract number | 330790 |
| Policy instance | 8 |
| BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 ) |
| Policy contract number | 103014 |
| Policy instance | 1 |
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AS5N |
| Policy instance | 2 |
| BLOCK VISION (National Association of Insurance Commissioners NAIC id number: 95387 ) |
| Policy contract number | 330790 |
| Policy instance | 3 |
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | G000AS5N |
| Policy instance | 3 |
| NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 ) |
| Policy contract number | 330790 |
| Policy instance | 2 |
| BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 ) |
| Policy contract number | 103014 |
| Policy instance | 1 |
