XPRESSDOCS PARTNERS, LTD has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan XPRESSDOCS EMPLOYEE WELFARE BENEFIT PLAN
Measure | Date | Value |
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2022: XPRESSDOCS EMPLOYEE WELFARE BENEFIT PLAN 2022 401k membership |
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Total participants, beginning-of-year | 2022-01-01 | 229 |
Total number of active participants reported on line 7a of the Form 5500 | 2022-01-01 | 253 |
Number of retired or separated participants receiving benefits | 2022-01-01 | 3 |
Number of other retired or separated participants entitled to future benefits | 2022-01-01 | 0 |
Total of all active and inactive participants | 2022-01-01 | 256 |
2021: XPRESSDOCS EMPLOYEE WELFARE BENEFIT PLAN 2021 401k membership |
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Total participants, beginning-of-year | 2021-01-01 | 240 |
Total number of active participants reported on line 7a of the Form 5500 | 2021-01-01 | 229 |
Number of retired or separated participants receiving benefits | 2021-01-01 | 4 |
Number of other retired or separated participants entitled to future benefits | 2021-01-01 | 0 |
Total of all active and inactive participants | 2021-01-01 | 233 |
2020: XPRESSDOCS EMPLOYEE WELFARE BENEFIT PLAN 2020 401k membership |
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Total participants, beginning-of-year | 2020-01-01 | 277 |
Total number of active participants reported on line 7a of the Form 5500 | 2020-01-01 | 240 |
Number of retired or separated participants receiving benefits | 2020-01-01 | 5 |
Number of other retired or separated participants entitled to future benefits | 2020-01-01 | 0 |
Total of all active and inactive participants | 2020-01-01 | 245 |
2019: XPRESSDOCS EMPLOYEE WELFARE BENEFIT PLAN 2019 401k membership |
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Total participants, beginning-of-year | 2019-01-01 | 250 |
Total number of active participants reported on line 7a of the Form 5500 | 2019-01-01 | 277 |
Number of retired or separated participants receiving benefits | 2019-01-01 | 2 |
Number of other retired or separated participants entitled to future benefits | 2019-01-01 | 0 |
Total of all active and inactive participants | 2019-01-01 | 279 |
2018: XPRESSDOCS EMPLOYEE WELFARE BENEFIT PLAN 2018 401k membership |
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Total participants, beginning-of-year | 2018-01-01 | 233 |
Total number of active participants reported on line 7a of the Form 5500 | 2018-01-01 | 250 |
Number of retired or separated participants receiving benefits | 2018-01-01 | 3 |
Number of other retired or separated participants entitled to future benefits | 2018-01-01 | 0 |
Total of all active and inactive participants | 2018-01-01 | 253 |
2017: XPRESSDOCS EMPLOYEE WELFARE BENEFIT PLAN 2017 401k membership |
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Total participants, beginning-of-year | 2017-01-01 | 218 |
Total number of active participants reported on line 7a of the Form 5500 | 2017-01-01 | 232 |
Number of retired or separated participants receiving benefits | 2017-01-01 | 1 |
Number of other retired or separated participants entitled to future benefits | 2017-01-01 | 0 |
Total of all active and inactive participants | 2017-01-01 | 233 |
2016: XPRESSDOCS EMPLOYEE WELFARE BENEFIT PLAN 2016 401k membership |
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Total participants, beginning-of-year | 2016-01-01 | 138 |
Total number of active participants reported on line 7a of the Form 5500 | 2016-01-01 | 218 |
Number of retired or separated participants receiving benefits | 2016-01-01 | 0 |
Number of other retired or separated participants entitled to future benefits | 2016-01-01 | 0 |
Total of all active and inactive participants | 2016-01-01 | 218 |
2015: XPRESSDOCS EMPLOYEE WELFARE BENEFIT PLAN 2015 401k membership |
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Total participants, beginning-of-year | 2015-01-01 | 139 |
Total number of active participants reported on line 7a of the Form 5500 | 2015-01-01 | 137 |
Number of retired or separated participants receiving benefits | 2015-01-01 | 1 |
Number of other retired or separated participants entitled to future benefits | 2015-01-01 | 0 |
Total of all active and inactive participants | 2015-01-01 | 138 |
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits | 2015-01-01 | 0 |
Total participants | 2015-01-01 | 138 |
Number of participants with account balances | 2015-01-01 | 0 |
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested | 2015-01-01 | 0 |
2014: XPRESSDOCS EMPLOYEE WELFARE BENEFIT PLAN 2014 401k membership |
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Total participants, beginning-of-year | 2014-01-01 | 131 |
Total number of active participants reported on line 7a of the Form 5500 | 2014-01-01 | 137 |
Number of retired or separated participants receiving benefits | 2014-01-01 | 2 |
Number of other retired or separated participants entitled to future benefits | 2014-01-01 | 0 |
Total of all active and inactive participants | 2014-01-01 | 139 |
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits | 2014-01-01 | 0 |
Total participants | 2014-01-01 | 139 |
Number of participants with account balances | 2014-01-01 | 0 |
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested | 2014-01-01 | 0 |
2013: XPRESSDOCS EMPLOYEE WELFARE BENEFIT PLAN 2013 401k membership |
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Total participants, beginning-of-year | 2013-01-01 | 147 |
Total number of active participants reported on line 7a of the Form 5500 | 2013-01-01 | 131 |
Number of retired or separated participants receiving benefits | 2013-01-01 | 0 |
Number of other retired or separated participants entitled to future benefits | 2013-01-01 | 0 |
Total of all active and inactive participants | 2013-01-01 | 131 |
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits | 2013-01-01 | 0 |
Total participants | 2013-01-01 | 131 |
Number of participants with account balances | 2013-01-01 | 0 |
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested | 2013-01-01 | 0 |
2022: XPRESSDOCS EMPLOYEE WELFARE BENEFIT PLAN 2022 form 5500 responses |
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2022-01-01 | Type of plan entity | Single employer plan |
2022-01-01 | Submission has been amended | No |
2022-01-01 | This submission is the final filing | No |
2022-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2022-01-01 | Plan is a collectively bargained plan | No |
2022-01-01 | Plan funding arrangement – Insurance | Yes |
2022-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2022-01-01 | Plan benefit arrangement – Insurance | Yes |
2022-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
2021: XPRESSDOCS EMPLOYEE WELFARE BENEFIT PLAN 2021 form 5500 responses |
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2021-01-01 | Type of plan entity | Single employer plan |
2021-01-01 | Submission has been amended | No |
2021-01-01 | This submission is the final filing | No |
2021-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2021-01-01 | Plan is a collectively bargained plan | No |
2021-01-01 | Plan funding arrangement – Insurance | Yes |
2021-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2021-01-01 | Plan benefit arrangement – Insurance | Yes |
2021-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
2020: XPRESSDOCS EMPLOYEE WELFARE BENEFIT PLAN 2020 form 5500 responses |
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2020-01-01 | Type of plan entity | Single employer plan |
2020-01-01 | Submission has been amended | No |
2020-01-01 | This submission is the final filing | No |
2020-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2020-01-01 | Plan is a collectively bargained plan | No |
2020-01-01 | Plan funding arrangement – Insurance | Yes |
2020-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2020-01-01 | Plan benefit arrangement – Insurance | Yes |
2020-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
2019: XPRESSDOCS EMPLOYEE WELFARE BENEFIT PLAN 2019 form 5500 responses |
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2019-01-01 | Type of plan entity | Single employer plan |
2019-01-01 | Submission has been amended | No |
2019-01-01 | This submission is the final filing | No |
2019-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2019-01-01 | Plan is a collectively bargained plan | No |
2019-01-01 | Plan funding arrangement – Insurance | Yes |
2019-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2019-01-01 | Plan benefit arrangement – Insurance | Yes |
2019-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
2018: XPRESSDOCS EMPLOYEE WELFARE BENEFIT PLAN 2018 form 5500 responses |
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2018-01-01 | Type of plan entity | Single employer plan |
2018-01-01 | Submission has been amended | No |
2018-01-01 | This submission is the final filing | No |
2018-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2018-01-01 | Plan is a collectively bargained plan | No |
2018-01-01 | Plan funding arrangement – Insurance | Yes |
2018-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
2018-01-01 | Plan benefit arrangement – Insurance | Yes |
2018-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
2017: XPRESSDOCS EMPLOYEE WELFARE BENEFIT PLAN 2017 form 5500 responses |
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2017-01-01 | Type of plan entity | Single employer plan |
2017-01-01 | Submission has been amended | No |
2017-01-01 | This submission is the final filing | No |
2017-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2017-01-01 | Plan is a collectively bargained plan | No |
2017-01-01 | Plan funding arrangement – Insurance | Yes |
2017-01-01 | Plan benefit arrangement – Insurance | Yes |
2016: XPRESSDOCS EMPLOYEE WELFARE BENEFIT PLAN 2016 form 5500 responses |
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2016-01-01 | Type of plan entity | Single employer plan |
2016-01-01 | Submission has been amended | No |
2016-01-01 | This submission is the final filing | No |
2016-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2016-01-01 | Plan is a collectively bargained plan | No |
2016-01-01 | Plan funding arrangement – Insurance | Yes |
2016-01-01 | Plan benefit arrangement – Insurance | Yes |
2015: XPRESSDOCS EMPLOYEE WELFARE BENEFIT PLAN 2015 form 5500 responses |
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2015-01-01 | Type of plan entity | Single employer plan |
2015-01-01 | Submission has been amended | No |
2015-01-01 | This submission is the final filing | No |
2015-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2015-01-01 | Plan is a collectively bargained plan | No |
2015-01-01 | Plan funding arrangement – Insurance | Yes |
2015-01-01 | Plan benefit arrangement – Insurance | Yes |
2014: XPRESSDOCS EMPLOYEE WELFARE BENEFIT PLAN 2014 form 5500 responses |
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2014-01-01 | Type of plan entity | Single employer plan |
2014-01-01 | Submission has been amended | No |
2014-01-01 | This submission is the final filing | No |
2014-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2014-01-01 | Plan is a collectively bargained plan | No |
2014-01-01 | Plan funding arrangement – Insurance | Yes |
2014-01-01 | Plan benefit arrangement – Insurance | Yes |
2013: XPRESSDOCS EMPLOYEE WELFARE BENEFIT PLAN 2013 form 5500 responses |
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2013-01-01 | Type of plan entity | Single employer plan |
2013-01-01 | First time form 5500 has been submitted | Yes |
2013-01-01 | Submission has been amended | No |
2013-01-01 | This submission is the final filing | No |
2013-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
2013-01-01 | Plan is a collectively bargained plan | No |
2013-01-01 | Plan funding arrangement – Insurance | Yes |
2013-01-01 | Plan benefit arrangement – Insurance | Yes |
BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 ) |
Policy contract number | 195633 |
Policy instance | 2 |
Insurance contract or identification number | 195633 | Number of Individuals Covered | 340 | Insurance policy start date | 2022-01-01 | Insurance policy end date | 2022-12-31 | Total amount of commissions paid to insurance broker | USD $83,136 | Total amount of fees paid to insurance company | USD $2,304 | 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 | 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 $2,192,629 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $83,136 | Amount paid for insurance broker fees | 2304 | Additional information about fees paid to insurance broker | SPECIAL PROGRAMS | Insurance broker organization code? | 3 |
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DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 ) |
Policy contract number | F027085 |
Policy instance | 1 |
Insurance contract or identification number | F027085 | Number of Individuals Covered | 253 | Insurance policy start date | 2022-01-01 | Insurance policy end date | 2022-12-31 | Total amount of commissions paid to insurance broker | USD $24,524 | 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 | Yes | 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 | ACCIDENTAL DEATH & DISMEMBERMENT | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $167,091 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $17,697 | Insurance broker organization code? | 3 |
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BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 ) |
Policy contract number | 195633 |
Policy instance | 5 |
Insurance contract or identification number | 195633 | Number of Individuals Covered | 294 | Insurance policy start date | 2021-01-01 | Insurance policy end date | 2021-12-31 | Total amount of commissions paid to insurance broker | USD $72,840 | Total amount of fees paid to insurance company | USD $1,278 | 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 $1,898,877 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $72,840 | Amount paid for insurance broker fees | 1278 | Additional information about fees paid to insurance broker | SPECIAL PROGRAMS | Insurance broker organization code? | 3 |
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SAFEGUARD HEALTH PLANS, INC. A TEXAS CORPORATION (National Association of Insurance Commissioners NAIC id number: 95051 ) |
Policy contract number | KM05957033 |
Policy instance | 4 |
Insurance contract or identification number | KM05957033 | Number of Individuals Covered | 79 | Insurance policy start date | 2021-01-01 | Insurance policy end date | 2021-12-31 | Total amount of commissions paid to insurance broker | USD $669 | Total amount of fees paid to insurance company | USD $145 | 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 $6,394 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $669 | Insurance broker organization code? | 3 | Amount paid for insurance broker fees | 145 | Additional information about fees paid to insurance broker | SUPPLEMENTAL COMPENSATION |
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METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
Policy contract number | 5957033 |
Policy instance | 3 |
Insurance contract or identification number | 5957033 | Number of Individuals Covered | 395 | Insurance policy start date | 2021-01-01 | Insurance policy end date | 2021-12-31 | Total amount of commissions paid to insurance broker | USD $12,443 | Total amount of fees paid to insurance company | USD $2,298 | 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 $123,768 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $12,443 | Amount paid for insurance broker fees | 34 | Additional information about fees paid to insurance broker | NON-MONETARY COMPENSATION | Insurance broker organization code? | 3 |
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NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 ) |
Policy contract number | 35195 |
Policy instance | 2 |
Insurance contract or identification number | 35195 | Number of Individuals Covered | 173 | Insurance policy start date | 2021-01-01 | Insurance policy end date | 2021-12-31 | Total amount of commissions paid to insurance broker | USD $1,883 | 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 | 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 $18,834 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $1,883 | Insurance broker organization code? | 3 |
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MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
Policy contract number | G000B4ST |
Policy instance | 1 |
Insurance contract or identification number | G000B4ST | Number of Individuals Covered | 229 | Insurance policy start date | 2021-01-01 | Insurance policy end date | 2021-12-31 | Total amount of commissions paid to insurance broker | USD $15,252 | Total amount of fees paid to insurance company | USD $4,295 | 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 | ACCIDENTAL DEATH AND DISMEMBERMENT | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $101,684 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $15,252 | Amount paid for insurance broker fees | 4295 | Additional information about fees paid to insurance broker | FEES PAID | Insurance broker organization code? | 3 |
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MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
Policy contract number | G000B4ST |
Policy instance | 1 |
Insurance contract or identification number | G000B4ST | Number of Individuals Covered | 240 | Insurance policy start date | 2020-01-01 | Insurance policy end date | 2020-12-31 | Total amount of commissions paid to insurance broker | USD $16,106 | Total amount of fees paid to insurance company | USD $6,164 | 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 | ACCIDENTAL DEATH AND DISMEMBERMENT | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $107,375 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $16,106 | Amount paid for insurance broker fees | 6164 | Additional information about fees paid to insurance broker | FEES PAID | Insurance broker organization code? | 3 |
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NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 ) |
Policy contract number | 35195 |
Policy instance | 2 |
Insurance contract or identification number | 35195 | Number of Individuals Covered | 177 | Insurance policy start date | 2020-01-01 | Insurance policy end date | 2020-12-31 | Total amount of commissions paid to insurance broker | USD $2,082 | 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 | 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 $20,822 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $2,082 | Insurance broker organization code? | 3 |
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METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
Policy contract number | 5957033 |
Policy instance | 3 |
Insurance contract or identification number | 5957033 | Number of Individuals Covered | 412 | Insurance policy start date | 2020-01-01 | Insurance policy end date | 2020-12-31 | Total amount of commissions paid to insurance broker | USD $11,258 | Total amount of fees paid to insurance company | USD $2,958 | 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 $122,293 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $11,258 | Amount paid for insurance broker fees | 24 | Additional information about fees paid to insurance broker | NON-MONETARY COMPENSATION | Insurance broker organization code? | 3 |
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SAFEGUARD HEALTH PLANS, INC. A TEXAS CORPORATION (National Association of Insurance Commissioners NAIC id number: 95051 ) |
Policy contract number | KM05957033 |
Policy instance | 4 |
Insurance contract or identification number | KM05957033 | Number of Individuals Covered | 122 | Insurance policy start date | 2020-01-01 | Insurance policy end date | 2020-12-31 | Total amount of commissions paid to insurance broker | USD $985 | Total amount of fees paid to insurance company | USD $288 | 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 $10,653 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $985 | Insurance broker organization code? | 3 | Amount paid for insurance broker fees | 288 | Additional information about fees paid to insurance broker | SUPPLEMENTAL COMPENSATION |
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BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 ) |
Policy contract number | 195633 |
Policy instance | 5 |
Insurance contract or identification number | 195633 | Number of Individuals Covered | 322 | Insurance policy start date | 2020-01-01 | Insurance policy end date | 2020-12-31 | Total amount of commissions paid to insurance broker | USD $80,700 | 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 | 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 $2,166,919 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $80,700 | Insurance broker organization code? | 3 |
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SAFEGUARD HEALTH PLANS, INC. A TEXAS CORPORATION (National Association of Insurance Commissioners NAIC id number: 95051 ) |
Policy contract number | 5957033 |
Policy instance | 4 |
Insurance contract or identification number | 5957033 | Number of Individuals Covered | 146 | Insurance policy start date | 2019-01-01 | Insurance policy end date | 2019-12-31 | Total amount of commissions paid to insurance broker | USD $1,180 | Total amount of fees paid to insurance company | USD $103 | 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 $11,801 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $825 | Insurance broker organization code? | 3 | Amount paid for insurance broker fees | 103 | Additional information about fees paid to insurance broker | SUPPLEMENTAL COMPENSATION |
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METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
Policy contract number | 5957033 |
Policy instance | 3 |
Insurance contract or identification number | 5957033 | Number of Individuals Covered | 400 | Insurance policy start date | 2019-01-01 | Insurance policy end date | 2019-12-31 | Total amount of commissions paid to insurance broker | USD $11,393 | Total amount of fees paid to insurance company | USD $996 | 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 $113,939 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $7,633 | Amount paid for insurance broker fees | 42 | Additional information about fees paid to insurance broker | NON-MONETARY COMPENSATION | Insurance broker organization code? | 3 |
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NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 ) |
Policy contract number | 35195 |
Policy instance | 2 |
Insurance contract or identification number | 35195 | Number of Individuals Covered | 199 | Insurance policy start date | 2019-01-01 | Insurance policy end date | 2019-12-31 | Total amount of commissions paid to insurance broker | USD $2,018 | 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 | 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 $20,182 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $2,018 | Insurance broker organization code? | 3 |
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MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
Policy contract number | G000B4ST |
Policy instance | 1 |
Insurance contract or identification number | G000B4ST | Number of Individuals Covered | 277 | Insurance policy start date | 2019-01-01 | Insurance policy end date | 2019-12-31 | Total amount of commissions paid to insurance broker | USD $16,808 | Total amount of fees paid to insurance company | USD $5,261 | 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 | ACCIDENTAL DEATH AND DISMEMBERMENT | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $112,061 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $11,410 | Insurance broker organization code? | 3 | Amount paid for insurance broker fees | 5261 | Additional information about fees paid to insurance broker | OTHER COMPENSATION |
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MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
Policy contract number | G000B4ST |
Policy instance | 1 |
Insurance contract or identification number | G000B4ST | Number of Individuals Covered | 250 | Insurance policy start date | 2018-01-01 | Insurance policy end date | 2018-12-31 | Total amount of commissions paid to insurance broker | USD $15,784 | Total amount of fees paid to insurance company | USD $2,430 | 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 | ACCIDENTAL DEATH AND DISMEMBERMENT | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $105,227 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $15,784 | Amount paid for insurance broker fees | 2430 | Additional information about fees paid to insurance broker | OTHER COMPENSATION | Insurance broker organization code? | 3 |
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THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
Policy contract number | 00532971 |
Policy instance | 2 |
Insurance contract or identification number | 00532971 | Number of Individuals Covered | 189 | Insurance policy start date | 2018-01-01 | Insurance policy end date | 2018-12-31 | Total amount of commissions paid to insurance broker | USD $12,486 | Total amount of fees paid to insurance company | USD $2,015 | 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 $124,861 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $12,486 | Amount paid for insurance broker fees | 2015 | Additional information about fees paid to insurance broker | FEES PAID | Insurance broker organization code? | 3 |
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NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 ) |
Policy contract number | 35195 |
Policy instance | 3 |
Insurance contract or identification number | 35195 | Number of Individuals Covered | 172 | Insurance policy start date | 2018-01-01 | Insurance policy end date | 2018-12-31 | Total amount of commissions paid to insurance broker | USD $1,957 | 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 | 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 $19,575 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $1,957 | Insurance broker organization code? | 3 |
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NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 ) |
Policy contract number | 35195 |
Policy instance | 3 |
Insurance contract or identification number | 35195 | Number of Individuals Covered | 314 | Insurance policy start date | 2017-01-01 | Insurance policy end date | 2017-12-31 | Total amount of commissions paid to insurance broker | USD $1,879 | 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 | 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 $20,227 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $1,879 | Insurance broker organization code? | 3 | Insurance broker name | WORTHAM - FORT WORTH INC |
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THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
Policy contract number | 00532971 |
Policy instance | 2 |
Insurance contract or identification number | 00532971 | Number of Individuals Covered | 184 | Insurance policy start date | 2017-01-01 | Insurance policy end date | 2017-12-31 | Total amount of commissions paid to insurance broker | USD $10,198 | 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 $101,976 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $10,198 | Insurance broker organization code? | 3 | Insurance broker name | WORTHAM-FORT WORTH, INC. |
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MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
Policy contract number | G000B4ST |
Policy instance | 1 |
Insurance contract or identification number | G000B4ST | Number of Individuals Covered | 232 | Insurance policy start date | 2017-01-01 | Insurance policy end date | 2017-12-31 | Total amount of commissions paid to insurance broker | USD $15,307 | 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 | ACCIDENTAL DEATH & DISMEMBERMENT | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $102,045 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $15,307 | Insurance broker organization code? | 3 | Insurance broker name | WORTHAM-FORT WORTH, INC. |
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UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
Policy contract number | 438377 |
Policy instance | 2 |
Insurance contract or identification number | 438377 | Number of Individuals Covered | 81 | Insurance policy start date | 2015-01-01 | Insurance policy end date | 2015-12-31 | Total amount of commissions paid to insurance broker | USD $4,566 | Total amount of fees paid to insurance company | USD $569 | 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 | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $0 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $4,566 | Amount paid for insurance broker fees | 569 | Insurance broker organization code? | 3 | Insurance broker name | WORTHAM-FORT WORTH, INC. |
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UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
Policy contract number | 468376 |
Policy instance | 1 |
Insurance contract or identification number | 468376 | Number of Individuals Covered | 137 | Insurance policy start date | 2015-01-01 | Insurance policy end date | 2015-12-31 | Total amount of commissions paid to insurance broker | USD $5,039 | Total amount of fees paid to insurance company | USD $672 | 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 | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $33,594 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $5,039 | Amount paid for insurance broker fees | 672 | Insurance broker organization code? | 3 | Insurance broker name | WORTHAM-FORT WORTH, INC. |
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UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
Policy contract number | 591858 |
Policy instance | 3 |
Insurance contract or identification number | 591858 | Number of Individuals Covered | 196 | Insurance policy start date | 2015-01-01 | Insurance policy end date | 2015-12-31 | Total amount of commissions paid to insurance broker | USD $46,047 | Total amount of fees paid to insurance company | USD $1,158 | 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 $0 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $46,047 | Amount paid for insurance broker fees | 1158 | Insurance broker organization code? | 3 | Insurance broker name | WORTHAM-FORT WORTH, INC. |
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ACE AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 22667 ) |
Policy contract number | 12007531 |
Policy instance | 4 |
Insurance contract or identification number | 12007531 | Number of Individuals Covered | 119 | Insurance policy start date | 2015-01-01 | Insurance policy end date | 2015-12-31 | Total amount of commissions paid to insurance broker | USD $5,950 | 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 | 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 $59,503 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $5,950 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 | Insurance broker name | WORTHAM-FORT WORTH, INC. |
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BLOCK VISION (National Association of Insurance Commissioners NAIC id number: 95387 ) |
Policy contract number | 326440 |
Policy instance | 5 |
Insurance contract or identification number | 326440 | Number of Individuals Covered | 189 | Insurance policy start date | 2015-01-01 | Insurance policy end date | 2015-12-31 | Total amount of commissions paid to insurance broker | USD $1,079 | 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 | 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 $10,794 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $1,079 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 | Insurance broker name | WORTHAM-FORT WORTH, INC. |
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MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
Policy contract number | GUG0AHU5 |
Policy instance | 2 |
Insurance contract or identification number | GUG0AHU5 | Number of Individuals Covered | 137 | Insurance policy start date | 2014-01-01 | Insurance policy end date | 2014-12-31 | Total amount of commissions paid to insurance broker | USD $2,008 | Total amount of fees paid to insurance company | USD $301 | 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 | 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 $13,386 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $2,008 | Amount paid for insurance broker fees | 301 | Additional information about fees paid to insurance broker | BONUS | Insurance broker organization code? | 3 | Insurance broker name | WORTHAM-FORT WORTH, INC. |
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MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
Policy contract number | GLUG0AHU5 |
Policy instance | 1 |
Insurance contract or identification number | GLUG0AHU5 | Number of Individuals Covered | 137 | Insurance policy start date | 2014-01-01 | Insurance policy end date | 2014-12-31 | Total amount of commissions paid to insurance broker | USD $752 | Total amount of fees paid to insurance company | USD $113 | 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 | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $5,016 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $752 | Amount paid for insurance broker fees | 113 | Additional information about fees paid to insurance broker | BONUS | Insurance broker organization code? | 3 | Insurance broker name | WORTHAM-FORT WORTH, INC. |
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MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
Policy contract number | GLTD0AHU5 |
Policy instance | 3 |
Insurance contract or identification number | GLTD0AHU5 | Number of Individuals Covered | 137 | Insurance policy start date | 2014-01-01 | Insurance policy end date | 2014-12-31 | Total amount of commissions paid to insurance broker | USD $2,310 | Total amount of fees paid to insurance company | USD $346 | 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 | 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 $15,401 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $2,310 | Amount paid for insurance broker fees | 346 | Additional information about fees paid to insurance broker | BONUS | Insurance broker organization code? | 3 | Insurance broker name | WORTHAM-FORT WORTH, INC. |
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MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
Policy contract number | GVTL0AHU5 |
Policy instance | 4 |
Insurance contract or identification number | GVTL0AHU5 | Number of Individuals Covered | 42 | Insurance policy start date | 2014-01-01 | Insurance policy end date | 2014-12-31 | Total amount of commissions paid to insurance broker | USD $1,637 | Total amount of fees paid to insurance company | USD $245 | 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 | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $10,914 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $1,637 | Amount paid for insurance broker fees | 245 | Additional information about fees paid to insurance broker | BONUS | Insurance broker organization code? | 3 | Insurance broker name | WORTHAM-FORT WORTH, INC. |
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UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
Policy contract number | 591858 |
Policy instance | 5 |
Insurance contract or identification number | 591858 | Number of Individuals Covered | 212 | Insurance policy start date | 2014-01-01 | Insurance policy end date | 2014-12-31 | Total amount of commissions paid to insurance broker | USD $38,374 | Total amount of fees paid to insurance company | USD $1,509 | 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 $959,357 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $38,374 | Amount paid for insurance broker fees | 1509 | Additional information about fees paid to insurance broker | BONUS | Insurance broker organization code? | 3 | Insurance broker name | WORTHAM-FORT WORTH, INC. |
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METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
Policy contract number | KM05914718 |
Policy instance | 6 |
Insurance contract or identification number | KM05914718 | Number of Individuals Covered | 143 | Insurance policy start date | 2014-01-01 | Insurance policy end date | 2014-12-31 | Total amount of commissions paid to insurance broker | USD $3,576 | 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 | 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 $38,987 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $3,576 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 | Insurance broker name | WORTHAM-FORT WORTH, INC. |
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BLOCK VISION (National Association of Insurance Commissioners NAIC id number: 95387 ) |
Policy contract number | 326440 |
Policy instance | 7 |
Insurance contract or identification number | 326440 | Number of Individuals Covered | 196 | Insurance policy start date | 2014-01-01 | Insurance policy end date | 2014-12-31 | Total amount of commissions paid to insurance broker | USD $1,015 | 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 | 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 $11,050 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $1,015 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 | Insurance broker name | WORTHAM-FORT WORTH, INC. |
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SAFEGUARD HEALTH PLANS, INC. A TEXAS CORPORATION (National Association of Insurance Commissioners NAIC id number: 95051 ) |
Policy contract number | KM05914718 |
Policy instance | 8 |
Insurance contract or identification number | KM05914718 | Number of Individuals Covered | 175 | Insurance policy start date | 2014-01-01 | Insurance policy end date | 2014-12-31 | Total amount of commissions paid to insurance broker | USD $1,292 | 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 | 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 $13,990 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $1,292 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 | Insurance broker name | WORTHAM- FORT WORTH, INC. |
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MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
Policy contract number | GUG0AHU5 |
Policy instance | 2 |
Insurance contract or identification number | GUG0AHU5 | Number of Individuals Covered | 131 | Insurance policy start date | 2013-01-01 | Insurance policy end date | 2013-12-31 | Total amount of commissions paid to insurance broker | USD $1,396 | Total amount of fees paid to insurance company | USD $149 | 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 | 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 $9,307 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $1,396 | Amount paid for insurance broker fees | 149 | Insurance broker organization code? | 3 | Insurance broker name | WORTHAM-FORT WORTH, INC. |
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MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
Policy contract number | GVTL0AHU5 |
Policy instance | 4 |
Insurance contract or identification number | GVTL0AHU5 | Number of Individuals Covered | 38 | Insurance policy start date | 2013-01-01 | Insurance policy end date | 2013-12-31 | Total amount of commissions paid to insurance broker | USD $1,504 | Total amount of fees paid to insurance company | USD $195 | 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 | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $10,028 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $1,504 | Amount paid for insurance broker fees | 195 | Insurance broker organization code? | 3 | Insurance broker name | WORTHAM-FORT WORTH, INC. |
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MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
Policy contract number | GLTD0AHU5 |
Policy instance | 3 |
Insurance contract or identification number | GLTD0AHU5 | Number of Individuals Covered | 131 | Insurance policy start date | 2013-01-01 | Insurance policy end date | 2013-12-31 | Total amount of commissions paid to insurance broker | USD $1,646 | Total amount of fees paid to insurance company | USD $160 | 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 | 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 $10,975 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $1,646 | Amount paid for insurance broker fees | 160 | Insurance broker organization code? | 3 | Insurance broker name | WORTHAM-FORT WORTH, INC. |
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UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
Policy contract number | 591858 |
Policy instance | 5 |
Insurance contract or identification number | 591858 | Number of Individuals Covered | 197 | Insurance policy start date | 2013-01-01 | Insurance policy end date | 2013-12-31 | Total amount of commissions paid to insurance broker | USD $34,373 | Total amount of fees paid to insurance company | USD $2,242 | 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 $803,507 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $34,373 | Amount paid for insurance broker fees | 2242 | Insurance broker organization code? | 3 | Insurance broker name | WORTHAM-FORT WORTH, INC. |
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THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) |
Policy contract number | 00473915 |
Policy instance | 6 |
Insurance contract or identification number | 00473915 | Number of Individuals Covered | 111 | Insurance policy start date | 2013-01-01 | Insurance policy end date | 2013-12-31 | Total amount of commissions paid to insurance broker | USD $5,812 | Total amount of fees paid to insurance company | USD $1,132 | 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 | 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 $58,121 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $5,812 | Amount paid for insurance broker fees | 1132 | Insurance broker organization code? | 3 | Insurance broker name | WORTHAM-FORT WORTH, INC. |
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BLOCK VISION (National Association of Insurance Commissioners NAIC id number: 95387 ) |
Policy contract number | 326440 |
Policy instance | 7 |
Insurance contract or identification number | 326440 | Number of Individuals Covered | 79 | Insurance policy start date | 2013-01-01 | Insurance policy end date | 2013-12-31 | Total amount of commissions paid to insurance broker | USD $888 | 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 | 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 $8,794 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $888 | Amount paid for insurance broker fees | 0 | Insurance broker organization code? | 3 | Insurance broker name | WORTHAM-FORT WORTH, INC. |
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MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
Policy contract number | GLUG0AHU5 |
Policy instance | 1 |
Insurance contract or identification number | GLUG0AHU5 | Number of Individuals Covered | 131 | Insurance policy start date | 2013-01-01 | Insurance policy end date | 2013-12-31 | Total amount of commissions paid to insurance broker | USD $647 | Total amount of fees paid to insurance company | USD $54 | 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 | No | Long Term Disability Insurance Welfare Benefit | No | Unemployment Insurance Welfare Benefit | No | Other welfare benefits provided | ACCIDENTAL DEATH & DISMEMBERMENT | Were dividends or retroactive rate refunds paid in cash? | No | Were dividends or retroactive rate refunds paid as a credit? | No | Welfare Benefit Premiums Paid to Carrier | USD $4,315 | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | Commission paid to Insurance Broker | USD $647 | Amount paid for insurance broker fees | 54 | Insurance broker organization code? | 3 | Insurance broker name | WORTHAM-FORT WORTH, INC. |
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