SFMC, LP DBA SERVICE FIRST MORTGAGE COMPANY has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan SFMC, LP EMPLOYEE BENEFITS PLAN
| CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 ) |
| Policy contract number | 00634977 |
| Policy instance | 8 |
| Insurance contract or identification number | 00634977 | | Number of Individuals Covered | 271 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $108,199 | | Health Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $703,571 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 108199 | | Additional information about fees paid to insurance broker | BENEFIT ADVISOR FEES & INCENTIVE COMPENSATION PAYMENTS | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG0AZ5F |
| Policy instance | 1 |
| Insurance contract or identification number | GLUG0AZ5F | | Number of Individuals Covered | 238 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2023-01-01 | | Total amount of commissions paid to insurance broker | USD $3,182 | | Total amount of fees paid to insurance company | USD $1,453 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $21,211 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,182 | | Amount paid for insurance broker fees | 1453 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUC0AZ5F |
| Policy instance | 2 |
| Insurance contract or identification number | GUC0AZ5F | | Number of Individuals Covered | 68 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2023-01-01 | | Total amount of commissions paid to insurance broker | USD $9,020 | | Total amount of fees paid to insurance company | USD $3,161 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $60,130 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $9,020 | | Amount paid for insurance broker fees | 3161 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GVTL0AZ5F |
| Policy instance | 3 |
| Insurance contract or identification number | GVTL0AZ5F | | Number of Individuals Covered | 98 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2023-01-01 | | Total amount of commissions paid to insurance broker | USD $5,290 | | Total amount of fees paid to insurance company | USD $2,075 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $35,266 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,290 | | Amount paid for insurance broker fees | 2075 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUDH0AZ5F |
| Policy instance | 4 |
| Insurance contract or identification number | GUDH0AZ5F | | Number of Individuals Covered | 50 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2023-01-01 | | Total amount of commissions paid to insurance broker | USD $2,215 | | Total amount of fees paid to insurance company | USD $1,019 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $14,769 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,215 | | Amount paid for insurance broker fees | 1019 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUDE0AZ5F |
| Policy instance | 5 |
| Insurance contract or identification number | GUDE0AZ5F | | Number of Individuals Covered | 33 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2023-01-01 | | Total amount of commissions paid to insurance broker | USD $1,247 | | Total amount of fees paid to insurance company | USD $525 | | Other welfare benefits provided | CRITICAL ILLNESS | | Welfare Benefit Premiums Paid to Carrier | USD $8,314 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,247 | | Amount paid for insurance broker fees | 525 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUPR0AZ5F |
| Policy instance | 6 |
| Insurance contract or identification number | GUPR0AZ5F | | Number of Individuals Covered | 63 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2023-01-01 | | Total amount of commissions paid to insurance broker | USD $4,401 | | Total amount of fees paid to insurance company | USD $1,530 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $29,342 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,401 | | Amount paid for insurance broker fees | 1530 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 913454 |
| Policy instance | 7 |
| Insurance contract or identification number | 913454 | | Number of Individuals Covered | 432 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $26,726 | | Total amount of fees paid to insurance company | USD $2,516 | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $175,083 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $26,726 | | Amount paid for insurance broker fees | 2516 | | Additional information about fees paid to insurance broker | SERVICE FEE AGREEMENT & BONUS AMOUNT | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG0AZ5F |
| Policy instance | 1 |
| Insurance contract or identification number | GLUG0AZ5F | | Number of Individuals Covered | 345 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2022-01-01 | | Total amount of commissions paid to insurance broker | USD $3,621 | | Total amount of fees paid to insurance company | USD $1,213 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $24,137 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,621 | | Amount paid for insurance broker fees | 1213 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUC0AZ5F |
| Policy instance | 2 |
| Insurance contract or identification number | GUC0AZ5F | | Number of Individuals Covered | 102 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2022-01-01 | | Total amount of commissions paid to insurance broker | USD $7,792 | | Total amount of fees paid to insurance company | USD $2,394 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $51,949 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,792 | | Amount paid for insurance broker fees | 2394 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GVTL0AZ5F |
| Policy instance | 3 |
| Insurance contract or identification number | GVTL0AZ5F | | Number of Individuals Covered | 124 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2022-01-01 | | Total amount of commissions paid to insurance broker | USD $5,113 | | Total amount of fees paid to insurance company | USD $1,624 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $34,089 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,113 | | Amount paid for insurance broker fees | 1624 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUDH0AZ5F |
| Policy instance | 4 |
| Insurance contract or identification number | GUDH0AZ5F | | Number of Individuals Covered | 71 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2022-01-01 | | Total amount of commissions paid to insurance broker | USD $2,559 | | Total amount of fees paid to insurance company | USD $944 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $17,063 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,559 | | Amount paid for insurance broker fees | 944 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUDE0AZ5F |
| Policy instance | 5 |
| Insurance contract or identification number | GUDE0AZ5F | | Number of Individuals Covered | 56 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2022-01-01 | | Total amount of commissions paid to insurance broker | USD $1,295 | | Total amount of fees paid to insurance company | USD $633 | | Other welfare benefits provided | CRITICAL ILLNESS | | Welfare Benefit Premiums Paid to Carrier | USD $8,632 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,295 | | Amount paid for insurance broker fees | 633 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUPR0AZ5F |
| Policy instance | 6 |
| Insurance contract or identification number | GUPR0AZ5F | | Number of Individuals Covered | 96 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2022-01-01 | | Total amount of commissions paid to insurance broker | USD $3,796 | | Total amount of fees paid to insurance company | USD $1,222 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $25,308 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,796 | | Amount paid for insurance broker fees | 1222 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 913454 |
| Policy instance | 7 |
| Insurance contract or identification number | 913454 | | Number of Individuals Covered | 606 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $19,385 | | Total amount of fees paid to insurance company | USD $131,331 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $2,994,622 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $19,385 | | Amount paid for insurance broker fees | 131331 | | Additional information about fees paid to insurance broker | SERVICE FEE AGREEMENT | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG0AZ5F |
| Policy instance | 1 |
| Insurance contract or identification number | GLUG0AZ5F | | Number of Individuals Covered | 310 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2021-01-01 | | Total amount of commissions paid to insurance broker | USD $2,985 | | Total amount of fees paid to insurance company | USD $1,002 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $19,898 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,985 | | Amount paid for insurance broker fees | 1002 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUC0AZ5F |
| Policy instance | 2 |
| Insurance contract or identification number | GUC0AZ5F | | Number of Individuals Covered | 83 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2021-01-01 | | Total amount of commissions paid to insurance broker | USD $5,795 | | Total amount of fees paid to insurance company | USD $1,687 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $38,634 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,795 | | Amount paid for insurance broker fees | 1687 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GVTL0AZ5F |
| Policy instance | 3 |
| Insurance contract or identification number | GVTL0AZ5F | | Number of Individuals Covered | 111 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2021-01-01 | | Total amount of commissions paid to insurance broker | USD $3,978 | | Total amount of fees paid to insurance company | USD $1,409 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $26,517 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,978 | | Amount paid for insurance broker fees | 1409 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUDH0AZ5F |
| Policy instance | 4 |
| Insurance contract or identification number | GUDH0AZ5F | | Number of Individuals Covered | 67 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2021-01-01 | | Total amount of commissions paid to insurance broker | USD $2,361 | | Total amount of fees paid to insurance company | USD $840 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $15,741 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,361 | | Amount paid for insurance broker fees | 840 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUDE0AZ5F |
| Policy instance | 5 |
| Insurance contract or identification number | GUDE0AZ5F | | Number of Individuals Covered | 47 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2021-01-01 | | Total amount of commissions paid to insurance broker | USD $1,606 | | Total amount of fees paid to insurance company | USD $569 | | Other welfare benefits provided | CRITICAL ILLNESS | | Welfare Benefit Premiums Paid to Carrier | USD $10,710 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,606 | | Amount paid for insurance broker fees | 569 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUPR0AZ5F |
| Policy instance | 6 |
| Insurance contract or identification number | GUPR0AZ5F | | Number of Individuals Covered | 89 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2021-01-01 | | Total amount of commissions paid to insurance broker | USD $2,903 | | Total amount of fees paid to insurance company | USD $669 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $19,355 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,903 | | Amount paid for insurance broker fees | 669 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 913454 |
| Policy instance | 7 |
| Insurance contract or identification number | 913454 | | Number of Individuals Covered | 524 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $16,608 | | Total amount of fees paid to insurance company | USD $117,211 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $2,471,243 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $16,608 | | Amount paid for insurance broker fees | 117211 | | Additional information about fees paid to insurance broker | SERVICE FEE AGREEMENT | | Insurance broker organization code? | 3 |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 913454 |
| Policy instance | 7 |
| Insurance contract or identification number | 913454 | | Number of Individuals Covered | 424 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $12,782 | | Total amount of fees paid to insurance company | USD $101,220 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $2,166,069 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $12,782 | | Amount paid for insurance broker fees | 96001 | | Additional information about fees paid to insurance broker | SERVICE FEE AGREEMENT | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUPR0AZ5F |
| Policy instance | 6 |
| Insurance contract or identification number | GUPR0AZ5F | | Number of Individuals Covered | 72 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2020-01-01 | | Total amount of commissions paid to insurance broker | USD $1,720 | | Total amount of fees paid to insurance company | USD $946 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $11,470 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,720 | | Amount paid for insurance broker fees | 946 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUDE0AZ5F |
| Policy instance | 5 |
| Insurance contract or identification number | GUDE0AZ5F | | Number of Individuals Covered | 42 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2020-01-01 | | Total amount of commissions paid to insurance broker | USD $1,390 | | Total amount of fees paid to insurance company | USD $590 | | Other welfare benefits provided | CRITICAL ILLNESS | | Welfare Benefit Premiums Paid to Carrier | USD $9,268 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,390 | | Amount paid for insurance broker fees | 590 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUDH0AZ5F |
| Policy instance | 4 |
| Insurance contract or identification number | GUDH0AZ5F | | Number of Individuals Covered | 51 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2020-01-01 | | Total amount of commissions paid to insurance broker | USD $1,985 | | Total amount of fees paid to insurance company | USD $407 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $13,236 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,985 | | Amount paid for insurance broker fees | 407 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GVTL0AZ5F |
| Policy instance | 3 |
| Insurance contract or identification number | GVTL0AZ5F | | Number of Individuals Covered | 78 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2020-01-01 | | Total amount of commissions paid to insurance broker | USD $3,436 | | Total amount of fees paid to insurance company | USD $1,011 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $22,910 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,436 | | Amount paid for insurance broker fees | 1011 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUC0AZ5F |
| Policy instance | 2 |
| Insurance contract or identification number | GUC0AZ5F | | Number of Individuals Covered | 63 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2020-01-01 | | Total amount of commissions paid to insurance broker | USD $4,124 | | Total amount of fees paid to insurance company | USD $1,778 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $27,493 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,124 | | Amount paid for insurance broker fees | 1778 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG0AZ5F |
| Policy instance | 1 |
| Insurance contract or identification number | GLUG0AZ5F | | Number of Individuals Covered | 250 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2020-01-01 | | Total amount of commissions paid to insurance broker | USD $2,387 | | Total amount of fees paid to insurance company | USD $622 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $15,910 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,387 | | Amount paid for insurance broker fees | 622 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 913454 |
| Policy instance | 7 |
| Insurance contract or identification number | 913454 | | Number of Individuals Covered | 356 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $10,938 | | Total amount of fees paid to insurance company | USD $84,139 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,700,310 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $10,938 | | Amount paid for insurance broker fees | 84139 | | Additional information about fees paid to insurance broker | SERVICE FEE AGREEMENT | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG0AZ5F |
| Policy instance | 1 |
| Insurance contract or identification number | GLUG0AZ5F | | Number of Individuals Covered | 145 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2019-01-01 | | Total amount of commissions paid to insurance broker | USD $1,964 | | Total amount of fees paid to insurance company | USD $1,027 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $13,090 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,964 | | Amount paid for insurance broker fees | 1027 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUC0AZ5F |
| Policy instance | 2 |
| Insurance contract or identification number | GUC0AZ5F | | Number of Individuals Covered | 45 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2019-01-01 | | Total amount of commissions paid to insurance broker | USD $5,498 | | Total amount of fees paid to insurance company | USD $1,939 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $36,653 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,498 | | Amount paid for insurance broker fees | 1939 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GVTL0AZ5F |
| Policy instance | 3 |
| Insurance contract or identification number | GVTL0AZ5F | | Number of Individuals Covered | 45 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2019-01-01 | | Total amount of commissions paid to insurance broker | USD $3,192 | | Total amount of fees paid to insurance company | USD $1,775 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $21,283 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,192 | | Amount paid for insurance broker fees | 1775 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUDH0AZ5F |
| Policy instance | 4 |
| Insurance contract or identification number | GUDH0AZ5F | | Number of Individuals Covered | 27 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2019-01-01 | | Total amount of commissions paid to insurance broker | USD $1,260 | | Total amount of fees paid to insurance company | USD $762 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $8,399 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,260 | | Amount paid for insurance broker fees | 762 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUDE0AZ5F |
| Policy instance | 5 |
| Insurance contract or identification number | GUDE0AZ5F | | Number of Individuals Covered | 42 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2019-01-01 | | Total amount of commissions paid to insurance broker | USD $1,800 | | Total amount of fees paid to insurance company | USD $585 | | Other welfare benefits provided | CRITICAL ILLNESS | | Welfare Benefit Premiums Paid to Carrier | USD $11,997 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,800 | | Amount paid for insurance broker fees | 585 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUPR0AZ5F |
| Policy instance | 6 |
| Insurance contract or identification number | GUPR0AZ5F | | Number of Individuals Covered | 46 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2019-01-01 | | Total amount of commissions paid to insurance broker | USD $2,918 | | Total amount of fees paid to insurance company | USD $844 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $19,457 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,918 | | Amount paid for insurance broker fees | 844 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG0AZ5F |
| Policy instance | 1 |
| Insurance contract or identification number | GLUG0AZ5F | | Number of Individuals Covered | 229 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2018-01-01 | | Total amount of commissions paid to insurance broker | USD $2,542 | | Total amount of fees paid to insurance company | USD $540 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $16,948 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,542 | | Amount paid for insurance broker fees | 540 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | MARSH & MCLENNAN AGENCY, LLC |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUC0AZ5F |
| Policy instance | 2 |
| Insurance contract or identification number | GUC0AZ5F | | Number of Individuals Covered | 63 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2018-01-01 | | Total amount of commissions paid to insurance broker | USD $4,734 | | Total amount of fees paid to insurance company | USD $862 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $31,561 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,734 | | Amount paid for insurance broker fees | 862 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | MARSH & MCLENNAN AGENCY, LLC |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GVTL0AZ5F |
| Policy instance | 3 |
| Insurance contract or identification number | GVTL0AZ5F | | Number of Individuals Covered | 84 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2018-01-01 | | Total amount of commissions paid to insurance broker | USD $4,473 | | Total amount of fees paid to insurance company | USD $1,033 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $29,823 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,473 | | Amount paid for insurance broker fees | 1033 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | MARSH & MCLENNAN AGENCY, LLC |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUDH0AZ5F |
| Policy instance | 4 |
| Insurance contract or identification number | GUDH0AZ5F | | Number of Individuals Covered | 47 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2018-01-01 | | Total amount of commissions paid to insurance broker | USD $1,935 | | Total amount of fees paid to insurance company | USD $394 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $12,900 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,935 | | Amount paid for insurance broker fees | 394 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | MARSH & MCLENNAN AGENCY, LLC |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUDE0AZ5F |
| Policy instance | 5 |
| Insurance contract or identification number | GUDE0AZ5F | | Number of Individuals Covered | 48 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2018-01-01 | | Total amount of commissions paid to insurance broker | USD $1,479 | | Total amount of fees paid to insurance company | USD $378 | | Other welfare benefits provided | CRITICAL ILLNESS | | Welfare Benefit Premiums Paid to Carrier | USD $9,862 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,479 | | Amount paid for insurance broker fees | 378 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | MARSH & MCLENNAN AGENCY, LLC |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GUPR0AZ5F |
| Policy instance | 6 |
| Insurance contract or identification number | GUPR0AZ5F | | Number of Individuals Covered | 74 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2018-01-01 | | Total amount of commissions paid to insurance broker | USD $2,023 | | Total amount of fees paid to insurance company | USD $379 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $13,487 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,023 | | Amount paid for insurance broker fees | 379 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | MARSH & MCLENNAN AGENCY, LLC |
|
| AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 ) |
| Policy contract number | 0761126 |
| Policy instance | 7 |
| Insurance contract or identification number | 0761126 | | Number of Individuals Covered | 423 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $10,668 | | Total amount of fees paid to insurance company | USD $13,018 | | Health Insurance Welfare Benefit | Yes | | Dental Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $2,236,177 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $10,668 | | Amount paid for insurance broker fees | 13018 | | Additional information about fees paid to insurance broker | JANUARY 2017 SALES INCENTIVE, 2016-2017 PPP INCENTIVE | | Insurance broker organization code? | 3 | | Insurance broker name | MARSH & MCLENNAN AGENCY, LLC |
|
| KANAWHA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65110 ) |
| Policy contract number | 896830 |
| Policy instance | 5 |
| Insurance contract or identification number | 896830 | | Number of Individuals Covered | 30 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $2,628 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $8,152 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,628 | | Insurance broker organization code? | 3 | | Insurance broker name | MC&H LIFE AGENCY, INC |
|
| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
| Policy contract number | 872847G |
| Policy instance | 1 |
| Insurance contract or identification number | 872847G | | Number of Individuals Covered | 403 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $13,261 | | 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 | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $88,407 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $13,261 | | Insurance broker organization code? | 3 | | Insurance broker name | MC&H LIFE AGENCY, INC |
|
| HUMANA (National Association of Insurance Commissioners NAIC id number: 70580 ) |
| Policy contract number | 624571 |
| Policy instance | 2 |
| Insurance contract or identification number | 624571 | | Number of Individuals Covered | 88 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $6,443 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $62,361 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,443 | | Insurance broker organization code? | 3 | | Insurance broker name | MC&H LIFE AGENCY, INC |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 814711 |
| Policy instance | 3 |
| Insurance contract or identification number | 814711 | | Number of Individuals Covered | 367 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $1,581 | | Total amount of fees paid to insurance company | USD $70,121 | | Health Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,353,394 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,581 | | Amount paid for insurance broker fees | 70121 | | Additional information about fees paid to insurance broker | SERVICE FEE AGREEMENT, BROKER BONUS | | Insurance broker organization code? | 3 | | Insurance broker name | MC&H LIFE AGENCY, INC |
|
| COMPBENEFITS (National Association of Insurance Commissioners NAIC id number: 95161 ) |
| Policy contract number | 624571 |
| Policy instance | 4 |
| Insurance contract or identification number | 624571 | | Number of Individuals Covered | 71 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $1,915 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $17,709 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,915 | | Insurance broker organization code? | 3 | | Insurance broker name | MC&H LIFE AGENCY, INC |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 814711 |
| Policy instance | 3 |
| Insurance contract or identification number | 814711 | | Number of Individuals Covered | 364 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $3,673 | | Total amount of fees paid to insurance company | USD $73,609 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Health Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,535,545 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,673 | | Amount paid for insurance broker fees | 73609 | | Additional information about fees paid to insurance broker | SERVICE FEE AGREEMENT | | Insurance broker organization code? | 3 | | Insurance broker name | MC&H LIFE AGENCY, INC |
|
| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
| Policy contract number | 872847G |
| Policy instance | 1 |
| Insurance contract or identification number | 872847G | | Number of Individuals Covered | 475 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $10,635 | | Total amount of fees paid to insurance company | USD $374 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $77,578 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $10,635 | | Amount paid for insurance broker fees | 374 | | Additional information about fees paid to insurance broker | BONUS PAID | | Insurance broker organization code? | 3 | | Insurance broker name | MC&H LIFE AGENCY, INC |
|
| HUMANA (National Association of Insurance Commissioners NAIC id number: 70580 ) |
| Policy contract number | 624571 |
| Policy instance | 2 |
| Insurance contract or identification number | 624571 | | Number of Individuals Covered | 163 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $10,537 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $115,359 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $10,537 | | Insurance broker organization code? | 3 | | Insurance broker name | MC&H LIFE AGENCY, INC |
|
| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
| Policy contract number | 872847G |
| Policy instance | 1 |
| Insurance contract or identification number | 872847G | | Number of Individuals Covered | 215 | | Insurance policy start date | 2013-10-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $3,013 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $13,412 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,013 | | Insurance broker organization code? | 3 | | Insurance broker name | MC&H LIFE AGENCY, INC |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 544816 |
| Policy instance | 3 |
| Insurance contract or identification number | 544816 | | Number of Individuals Covered | 359 | | Insurance policy start date | 2013-10-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $10,903 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Health Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $200,365 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $10,903 | | Insurance broker organization code? | 3 | | Insurance broker name | MC&H LIFE AGENCY, INC |
|
| HUMANA (National Association of Insurance Commissioners NAIC id number: 70580 ) |
| Policy contract number | 624571 |
| Policy instance | 2 |
| Insurance contract or identification number | 624571 | | Number of Individuals Covered | 152 | | Insurance policy start date | 2013-10-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $2,653 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $26,732 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,653 | | Insurance broker organization code? | 3 | | Insurance broker name | MC&H LIFE AGENCY, INC |
|
| HUMANA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 73288 ) |
| Policy contract number | 624571 |
| Policy instance | 2 |
| Insurance contract or identification number | 624571 | | Number of Individuals Covered | 158 | | Insurance policy start date | 2012-10-01 | | Insurance policy end date | 2013-09-30 | | Total amount of commissions paid to insurance broker | USD $10,547 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $98,008 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $10,547 | | Insurance broker organization code? | 3 | | Insurance broker name | MC&H LIFE AGENCY, INC |
|
| HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 ) |
| Policy contract number | 872847G |
| Policy instance | 1 |
| Insurance contract or identification number | 872847G | | Number of Individuals Covered | 226 | | Insurance policy start date | 2012-10-01 | | Insurance policy end date | 2013-09-30 | | Total amount of commissions paid to insurance broker | USD $10,615 | | Total amount of fees paid to insurance company | USD $2,013 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | AD&D | | Welfare Benefit Premiums Paid to Carrier | USD $70,765 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $10,615 | | Amount paid for insurance broker fees | 2013 | | Additional information about fees paid to insurance broker | BROKER BONUS | | Insurance broker organization code? | 3 | | Insurance broker name | MC&H LIFE AGENCY, INC |
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| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 544816 |
| Policy instance | 3 |
| Insurance contract or identification number | 544816 | | Number of Individuals Covered | 355 | | Insurance policy start date | 2012-10-01 | | Insurance policy end date | 2013-09-30 | | Total amount of commissions paid to insurance broker | USD $49,985 | | Total amount of fees paid to insurance company | USD $0 | | Contract purchased, in whole or in part, to distribute benefits from a terminating plan | No | | Contracts With Unallocated Funds Deposit Administration | 0 | | Health Insurance Welfare Benefit | Yes | | Vision Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,065,059 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $49,921 | | Insurance broker organization code? | 3 | | Insurance broker name | PAYCHEX INSURANCE AGENCY, INC |
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