AWES.ME, INC. has sponsored the creation of one or more 401k plans.
Additional information about AWES.ME, INC.
Submission information for form 5500 for 401k plan SMUGMUG INC. EMPLOYEE BENEFIT PLAN
401k plan membership statisitcs for SMUGMUG INC. EMPLOYEE BENEFIT PLAN
| Measure | Date | Value |
|---|
| 2022: SMUGMUG INC. EMPLOYEE BENEFIT PLAN 2022 401k membership |
|---|
| Total participants, beginning-of-year | 2022-04-01 | 180 |
| Total number of active participants reported on line 7a of the Form 5500 | 2022-04-01 | 166 |
| Number of retired or separated participants receiving benefits | 2022-04-01 | 8 |
| Number of other retired or separated participants entitled to future benefits | 2022-04-01 | 0 |
| Total of all active and inactive participants | 2022-04-01 | 174 |
| 2021: SMUGMUG INC. EMPLOYEE BENEFIT PLAN 2021 401k membership |
|---|
| Total participants, beginning-of-year | 2021-04-01 | 180 |
| Total number of active participants reported on line 7a of the Form 5500 | 2021-04-01 | 172 |
| Number of retired or separated participants receiving benefits | 2021-04-01 | 8 |
| Number of other retired or separated participants entitled to future benefits | 2021-04-01 | 0 |
| Total of all active and inactive participants | 2021-04-01 | 180 |
| 2020: SMUGMUG INC. EMPLOYEE BENEFIT PLAN 2020 401k membership |
|---|
| Total participants, beginning-of-year | 2020-04-01 | 187 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-04-01 | 176 |
| Number of retired or separated participants receiving benefits | 2020-04-01 | 4 |
| Number of other retired or separated participants entitled to future benefits | 2020-04-01 | 0 |
| Total of all active and inactive participants | 2020-04-01 | 180 |
| 2019: SMUGMUG INC. EMPLOYEE BENEFIT PLAN 2019 401k membership |
|---|
| Total participants, beginning-of-year | 2019-04-01 | 155 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-04-01 | 181 |
| Number of retired or separated participants receiving benefits | 2019-04-01 | 6 |
| Number of other retired or separated participants entitled to future benefits | 2019-04-01 | 0 |
| Total of all active and inactive participants | 2019-04-01 | 187 |
| 2018: SMUGMUG INC. EMPLOYEE BENEFIT PLAN 2018 401k membership |
|---|
| Total participants, beginning-of-year | 2018-04-01 | 115 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-04-01 | 154 |
| Number of retired or separated participants receiving benefits | 2018-04-01 | 5 |
| Number of other retired or separated participants entitled to future benefits | 2018-04-01 | 0 |
| Total of all active and inactive participants | 2018-04-01 | 159 |
| 2017: SMUGMUG INC. EMPLOYEE BENEFIT PLAN 2017 401k membership |
|---|
| Total participants, beginning-of-year | 2017-04-01 | 116 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-04-01 | 115 |
| Number of retired or separated participants receiving benefits | 2017-04-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2017-04-01 | 0 |
| Total of all active and inactive participants | 2017-04-01 | 115 |
| 2016: SMUGMUG INC. EMPLOYEE BENEFIT PLAN 2016 401k membership |
|---|
| Total participants, beginning-of-year | 2016-06-01 | 115 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-06-01 | 114 |
| Number of retired or separated participants receiving benefits | 2016-06-01 | 2 |
| Number of other retired or separated participants entitled to future benefits | 2016-06-01 | 0 |
| Total of all active and inactive participants | 2016-06-01 | 116 |
| 2015: SMUGMUG INC. EMPLOYEE BENEFIT PLAN 2015 401k membership |
|---|
| Total participants, beginning-of-year | 2015-06-01 | 118 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-06-01 | 113 |
| Number of retired or separated participants receiving benefits | 2015-06-01 | 2 |
| Number of other retired or separated participants entitled to future benefits | 2015-06-01 | 0 |
| Total of all active and inactive participants | 2015-06-01 | 115 |
| 2014: SMUGMUG INC. EMPLOYEE BENEFIT PLAN 2014 401k membership |
|---|
| Total participants, beginning-of-year | 2014-06-01 | 112 |
| Total number of active participants reported on line 7a of the Form 5500 | 2014-06-01 | 115 |
| Number of retired or separated participants receiving benefits | 2014-06-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2014-06-01 | 0 |
| Total of all active and inactive participants | 2014-06-01 | 115 |
| 2013: SMUGMUG INC. EMPLOYEE BENEFIT PLAN 2013 401k membership |
|---|
| Total participants, beginning-of-year | 2013-06-01 | 100 |
| Total number of active participants reported on line 7a of the Form 5500 | 2013-06-01 | 112 |
| Number of retired or separated participants receiving benefits | 2013-06-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2013-06-01 | 0 |
| Total of all active and inactive participants | 2013-06-01 | 112 |
| 2022: SMUGMUG INC. EMPLOYEE BENEFIT PLAN 2022 form 5500 responses |
|---|
| 2022-04-01 | Type of plan entity | Single employer plan |
| 2022-04-01 | Submission has been amended | No |
| 2022-04-01 | This submission is the final filing | No |
| 2022-04-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2022-04-01 | Plan is a collectively bargained plan | No |
| 2022-04-01 | Plan funding arrangement – Insurance | Yes |
| 2022-04-01 | Plan benefit arrangement – Insurance | Yes |
| 2021: SMUGMUG INC. EMPLOYEE BENEFIT PLAN 2021 form 5500 responses |
|---|
| 2021-04-01 | Type of plan entity | Single employer plan |
| 2021-04-01 | Submission has been amended | No |
| 2021-04-01 | This submission is the final filing | No |
| 2021-04-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2021-04-01 | Plan is a collectively bargained plan | No |
| 2021-04-01 | Plan funding arrangement – Insurance | Yes |
| 2021-04-01 | Plan benefit arrangement – Insurance | Yes |
| 2020: SMUGMUG INC. EMPLOYEE BENEFIT PLAN 2020 form 5500 responses |
|---|
| 2020-04-01 | Type of plan entity | Single employer plan |
| 2020-04-01 | Submission has been amended | No |
| 2020-04-01 | This submission is the final filing | No |
| 2020-04-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2020-04-01 | Plan is a collectively bargained plan | No |
| 2020-04-01 | Plan funding arrangement – Insurance | Yes |
| 2020-04-01 | Plan benefit arrangement – Insurance | Yes |
| 2019: SMUGMUG INC. EMPLOYEE BENEFIT PLAN 2019 form 5500 responses |
|---|
| 2019-04-01 | Type of plan entity | Single employer plan |
| 2019-04-01 | Submission has been amended | No |
| 2019-04-01 | This submission is the final filing | No |
| 2019-04-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2019-04-01 | Plan is a collectively bargained plan | No |
| 2019-04-01 | Plan funding arrangement – Insurance | Yes |
| 2019-04-01 | Plan benefit arrangement – Insurance | Yes |
| 2018: SMUGMUG INC. EMPLOYEE BENEFIT PLAN 2018 form 5500 responses |
|---|
| 2018-04-01 | Type of plan entity | Single employer plan |
| 2018-04-01 | Submission has been amended | No |
| 2018-04-01 | This submission is the final filing | No |
| 2018-04-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2018-04-01 | Plan is a collectively bargained plan | No |
| 2018-04-01 | Plan funding arrangement – Insurance | Yes |
| 2018-04-01 | Plan benefit arrangement – Insurance | Yes |
| 2017: SMUGMUG INC. EMPLOYEE BENEFIT PLAN 2017 form 5500 responses |
|---|
| 2017-04-01 | Type of plan entity | Single employer plan |
| 2017-04-01 | Submission has been amended | No |
| 2017-04-01 | This submission is the final filing | No |
| 2017-04-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2017-04-01 | Plan is a collectively bargained plan | No |
| 2017-04-01 | Plan funding arrangement – Insurance | Yes |
| 2017-04-01 | Plan benefit arrangement – Insurance | Yes |
| 2016: SMUGMUG INC. EMPLOYEE BENEFIT PLAN 2016 form 5500 responses |
|---|
| 2016-06-01 | Type of plan entity | Single employer plan |
| 2016-06-01 | Submission has been amended | No |
| 2016-06-01 | This submission is the final filing | No |
| 2016-06-01 | This return/report is a short plan year return/report (less than 12 months) | Yes |
| 2016-06-01 | Plan is a collectively bargained plan | No |
| 2016-06-01 | Plan funding arrangement – Insurance | Yes |
| 2016-06-01 | Plan benefit arrangement – Insurance | Yes |
| 2015: SMUGMUG INC. EMPLOYEE BENEFIT PLAN 2015 form 5500 responses |
|---|
| 2015-06-01 | Type of plan entity | Single employer plan |
| 2015-06-01 | Submission has been amended | No |
| 2015-06-01 | This submission is the final filing | No |
| 2015-06-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2015-06-01 | Plan is a collectively bargained plan | No |
| 2015-06-01 | Plan funding arrangement – Insurance | Yes |
| 2015-06-01 | Plan benefit arrangement – Insurance | Yes |
| 2014: SMUGMUG INC. EMPLOYEE BENEFIT PLAN 2014 form 5500 responses |
|---|
| 2014-06-01 | Type of plan entity | Single employer plan |
| 2014-06-01 | Submission has been amended | No |
| 2014-06-01 | This submission is the final filing | No |
| 2014-06-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2014-06-01 | Plan is a collectively bargained plan | No |
| 2014-06-01 | Plan funding arrangement – Insurance | Yes |
| 2014-06-01 | Plan benefit arrangement – Insurance | Yes |
| 2013: SMUGMUG INC. EMPLOYEE BENEFIT PLAN 2013 form 5500 responses |
|---|
| 2013-06-01 | Type of plan entity | Single employer plan |
| 2013-06-01 | First time form 5500 has been submitted | Yes |
| 2013-06-01 | Submission has been amended | No |
| 2013-06-01 | This submission is the final filing | No |
| 2013-06-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2013-06-01 | Plan is a collectively bargained plan | No |
| 2013-06-01 | Plan funding arrangement – Insurance | Yes |
| 2013-06-01 | Plan benefit arrangement – Insurance | Yes |
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 927625 |
| Policy instance | 5 |
| Insurance contract or identification number | 927625 | | Number of Individuals Covered | 428 | | Insurance policy start date | 2022-04-01 | | Insurance policy end date | 2023-03-31 | | Total amount of commissions paid to insurance broker | USD $107,523 | | 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 $2,150,455 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $107,523 | | Insurance broker organization code? | 3 |
|
| ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 ) |
| Policy contract number | L05457 |
| Policy instance | 4 |
| Insurance contract or identification number | L05457 | | Number of Individuals Covered | 429 | | Insurance policy start date | 2022-04-01 | | Insurance policy end date | 2023-03-31 | | Total amount of commissions paid to insurance broker | USD $20,492 | | 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 $240,770 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $20,492 | | Insurance broker organization code? | 3 |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 30090295 |
| Policy instance | 3 |
| Insurance contract or identification number | 30090295 | | Number of Individuals Covered | 159 | | Insurance policy start date | 2022-04-01 | | Insurance policy end date | 2023-03-31 | | Total amount of commissions paid to insurance broker | USD $347 | | 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 $27,885 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $347 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GVTL0AJ8I |
| Policy instance | 2 |
| Insurance contract or identification number | GVTL0AJ8I | | Number of Individuals Covered | 63 | | Insurance policy start date | 2022-04-01 | | Insurance policy end date | 2023-03-31 | | Total amount of commissions paid to insurance broker | USD $4,087 | | Total amount of fees paid to insurance company | USD $1,440 | | 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 | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | VOLUNTARY LIFE, VOLUNTARY AD&D | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $27,248 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,087 | | Amount paid for insurance broker fees | 1440 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG0AJ8I |
| Policy instance | 1 |
| Insurance contract or identification number | GLUG0AJ8I | | Number of Individuals Covered | 166 | | Insurance policy start date | 2022-04-01 | | Insurance policy end date | 2023-03-31 | | Total amount of commissions paid to insurance broker | USD $2,071 | | Total amount of fees paid to insurance company | USD $1,174 | | 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 | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | AD&D | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $20,712 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,071 | | Amount paid for insurance broker fees | 1174 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG0AJ8I |
| Policy instance | 1 |
| Insurance contract or identification number | GLUG0AJ8I | | Number of Individuals Covered | 172 | | Insurance policy start date | 2021-04-01 | | Insurance policy end date | 2022-03-31 | | Total amount of commissions paid to insurance broker | USD $2,229 | | Total amount of fees paid to insurance company | USD $1,261 | | 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 | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | AD&D | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $22,286 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,229 | | Amount paid for insurance broker fees | 1261 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 ) |
| Policy contract number | W0064612 |
| Policy instance | 2 |
| Insurance contract or identification number | W0064612 | | Number of Individuals Covered | 452 | | Insurance policy start date | 2021-04-01 | | Insurance policy end date | 2022-03-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $124,191 | | 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 $2,403,109 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 124191 | | Additional information about fees paid to insurance broker | PRODUCER SERVICE FEES | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GVTL0AJ8I |
| Policy instance | 3 |
| Insurance contract or identification number | GVTL0AJ8I | | Number of Individuals Covered | 63 | | Insurance policy start date | 2021-04-01 | | Insurance policy end date | 2022-03-31 | | Total amount of commissions paid to insurance broker | USD $3,751 | | Total amount of fees paid to insurance company | USD $1,459 | | 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 | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | VOLUNTARY LIFE, VOLUNTARY AD&D | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $25,010 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,751 | | Amount paid for insurance broker fees | 1459 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| HUMANA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 73288 ) |
| Policy contract number | 825729 |
| Policy instance | 4 |
| Insurance contract or identification number | 825729 | | Number of Individuals Covered | 170 | | Insurance policy start date | 2021-04-01 | | Insurance policy end date | 2022-03-31 | | Total amount of commissions paid to insurance broker | USD $28,117 | | 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 $290,454 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $28,117 | | Insurance broker organization code? | 3 |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 30090295 |
| Policy instance | 5 |
| Insurance contract or identification number | 30090295 | | Number of Individuals Covered | 164 | | Insurance policy start date | 2021-04-01 | | Insurance policy end date | 2022-03-31 | | Total amount of commissions paid to insurance broker | USD $378 | | 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 $30,088 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $378 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG0AJ8I |
| Policy instance | 1 |
| Insurance contract or identification number | GLUG0AJ8I | | Number of Individuals Covered | 176 | | Insurance policy start date | 2020-04-01 | | Insurance policy end date | 2021-03-31 | | Total amount of commissions paid to insurance broker | USD $2,290 | | Total amount of fees paid to insurance company | USD $1,245 | | 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 | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | AD&D | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $22,905 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,386 | | Amount paid for insurance broker fees | 1245 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 ) |
| Policy contract number | W0064612 |
| Policy instance | 2 |
| Insurance contract or identification number | W0064612 | | Number of Individuals Covered | 491 | | Insurance policy start date | 2020-04-01 | | Insurance policy end date | 2021-03-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $158,728 | | 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 $2,243,671 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 119137 | | Additional information about fees paid to insurance broker | PRODUCER SERVICE FEES ($117,189), BONUS OVERRIDE ($1,948) | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GVTL0AJ8I |
| Policy instance | 3 |
| Insurance contract or identification number | GVTL0AJ8I | | Number of Individuals Covered | 70 | | Insurance policy start date | 2020-04-01 | | Insurance policy end date | 2021-03-31 | | Total amount of commissions paid to insurance broker | USD $4,220 | | Total amount of fees paid to insurance company | USD $1,535 | | 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 | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | VOLUNTARY LIFE, VOLUNTARY AD&D | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $28,131 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,531 | | Amount paid for insurance broker fees | 1535 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| HUMANA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 73288 ) |
| Policy contract number | 825729 |
| Policy instance | 4 |
| Insurance contract or identification number | 825729 | | Number of Individuals Covered | 176 | | Insurance policy start date | 2020-04-01 | | Insurance policy end date | 2021-03-31 | | Total amount of commissions paid to insurance broker | USD $28,212 | | Total amount of fees paid to insurance company | USD $3,932 | | 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 $285,601 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $16,432 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 3932 | | Additional information about fees paid to insurance broker | BONUS |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 30090295 |
| Policy instance | 5 |
| Insurance contract or identification number | 30090295 | | Number of Individuals Covered | 174 | | Insurance policy start date | 2020-04-01 | | Insurance policy end date | 2021-03-31 | | Total amount of commissions paid to insurance broker | USD $225 | | 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 $31,089 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $225 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG0AJ8I |
| Policy instance | 1 |
| Insurance contract or identification number | GLUG0AJ8I | | Number of Individuals Covered | 181 | | Insurance policy start date | 2019-04-01 | | Insurance policy end date | 2020-03-31 | | Total amount of commissions paid to insurance broker | USD $2,297 | | Total amount of fees paid to insurance company | USD $1,419 | | 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 | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | AD&D | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $22,974 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,297 | | Amount paid for insurance broker fees | 1419 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 ) |
| Policy contract number | W0064612 |
| Policy instance | 2 |
| Insurance contract or identification number | W0064612 | | Number of Individuals Covered | 491 | | Insurance policy start date | 2019-04-01 | | Insurance policy end date | 2020-03-31 | | Total amount of commissions paid to insurance broker | USD $-8 | | Total amount of fees paid to insurance company | USD $125,762 | | 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 | 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 $2,344,929 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $-8 | | Amount paid for insurance broker fees | 125762 | | Additional information about fees paid to insurance broker | PRODUCER SERVICE FEES ($123,732), BONUS OVERRIDE ($1,925), MISC GIFTS & ENTERTAINMENT ALLOCATION ($105) | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GVTL0AJ8I |
| Policy instance | 3 |
| Insurance contract or identification number | GVTL0AJ8I | | Number of Individuals Covered | 67 | | Insurance policy start date | 2019-04-01 | | Insurance policy end date | 2020-03-31 | | Total amount of commissions paid to insurance broker | USD $4,305 | | Total amount of fees paid to insurance company | USD $1,704 | | 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 | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | VOLUNTARY LIFE, VOLUNTARY AD&D | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $28,702 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,305 | | Amount paid for insurance broker fees | 1704 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| HUMANA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 73288 ) |
| Policy contract number | 825729 |
| Policy instance | 4 |
| Insurance contract or identification number | 825729 | | Number of Individuals Covered | 184 | | Insurance policy start date | 2019-04-01 | | Insurance policy end date | 2020-03-31 | | Total amount of commissions paid to insurance broker | USD $26,252 | | Total amount of fees paid to insurance company | USD $7,767 | | 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 $264,522 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $26,252 | | Amount paid for insurance broker fees | 7767 | | Additional information about fees paid to insurance broker | BONUS | | Insurance broker organization code? | 3 |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 ) |
| Policy contract number | 30090295 |
| Policy instance | 5 |
| Insurance contract or identification number | 30090295 | | Number of Individuals Covered | 180 | | Insurance policy start date | 2019-04-01 | | Insurance policy end date | 2020-03-31 | | 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 $30,041 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 ) |
| Policy contract number | CA00105-201701 |
| Policy instance | 4 |
| Insurance contract or identification number | CA00105-201701 | | Number of Individuals Covered | 388 | | Insurance policy start date | 2018-04-01 | | Insurance policy end date | 2019-03-31 | | Total amount of commissions paid to insurance broker | USD $13,838 | | 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 $172,969 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $13,838 | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GVTL0AJ8I |
| Policy instance | 3 |
| Insurance contract or identification number | GVTL0AJ8I | | Number of Individuals Covered | 45 | | Insurance policy start date | 2018-04-01 | | Insurance policy end date | 2019-03-31 | | Total amount of commissions paid to insurance broker | USD $2,696 | | Total amount of fees paid to insurance company | USD $877 | | 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 | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | VOLUNTARY LIFE, VOLUNTARY AD&D | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $17,976 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,696 | | Amount paid for insurance broker fees | 877 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 ) |
| Policy contract number | W0064612 |
| Policy instance | 2 |
| Insurance contract or identification number | W0064612 | | Number of Individuals Covered | 395 | | Insurance policy start date | 2018-04-01 | | Insurance policy end date | 2019-03-31 | | Total amount of commissions paid to insurance broker | USD $92,486 | | Total amount of fees paid to insurance company | USD $7,880 | | 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 | 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 $1,824,806 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $92,486 | | Amount paid for insurance broker fees | 7880 | | Additional information about fees paid to insurance broker | BONUS OVERRIDE ($7,824), MISC GIFTS & ENTERTAINMENT ALLOCATION ($56) | | Insurance broker organization code? | 3 |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG0AJ8I |
| Policy instance | 1 |
| Insurance contract or identification number | GLUG0AJ8I | | Number of Individuals Covered | 154 | | Insurance policy start date | 2018-04-01 | | Insurance policy end date | 2019-03-31 | | Total amount of commissions paid to insurance broker | USD $1,721 | | Total amount of fees paid to insurance company | USD $823 | | 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 | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | AD&D | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $17,205 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,721 | | Amount paid for insurance broker fees | 823 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 |
|
| NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 ) |
| Policy contract number | CA00330-201704 |
| Policy instance | 5 |
| Insurance contract or identification number | CA00330-201704 | | Number of Individuals Covered | 279 | | Insurance policy start date | 2017-04-01 | | Insurance policy end date | 2018-03-31 | | Total amount of commissions paid to insurance broker | USD $10,908 | | 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 $136,353 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $10,908 | | Insurance broker organization code? | 3 | | Insurance broker name | FILICE INSURANCE AGENCY |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GVTL0AJ8I |
| Policy instance | 4 |
| Insurance contract or identification number | GVTL0AJ8I | | Number of Individuals Covered | 33 | | Insurance policy start date | 2017-04-01 | | Insurance policy end date | 2018-03-31 | | Total amount of commissions paid to insurance broker | USD $2,288 | | Total amount of fees paid to insurance company | USD $637 | | 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 | No | | Temporary Disability Insurance Welfare Benefit | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | VOLUNTARY LIFE, VOLUNTARY AD&D | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $15,254 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,288 | | Amount paid for insurance broker fees | 637 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | RON FILICE ENTERPRISES, INC |
|
| CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 ) |
| Policy contract number | W0064612 |
| Policy instance | 3 |
| Insurance contract or identification number | W0064612 | | Number of Individuals Covered | 278 | | Insurance policy start date | 2017-04-01 | | Insurance policy end date | 2018-03-31 | | Total amount of commissions paid to insurance broker | USD $68,002 | | 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 | 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 $1,340,613 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $68,002 | | Insurance broker organization code? | 3 | | Insurance broker name | RON FILICE ENTERPRISES, INC |
|
| ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 ) |
| Policy contract number | 277891 |
| Policy instance | 2 |
| Insurance contract or identification number | 277891 | | Number of Individuals Covered | 168 | | Insurance policy start date | 2017-04-01 | | Insurance policy end date | 2018-03-31 | | Total amount of commissions paid to insurance broker | USD $4,745 | | 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 | 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 $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 $4,745 | | Insurance broker organization code? | 3 | | Insurance broker name | RON FILICE ENTERPRISES, INC |
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| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG0AJ8I |
| Policy instance | 1 |
| Insurance contract or identification number | GLUG0AJ8I | | Number of Individuals Covered | 115 | | Insurance policy start date | 2017-04-01 | | Insurance policy end date | 2018-03-31 | | Total amount of commissions paid to insurance broker | USD $1,592 | | Total amount of fees paid to insurance company | USD $715 | | 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 | No | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | AD&D | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $15,921 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,592 | | Amount paid for insurance broker fees | 715 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | RON FILICE ENTERPRISES, INC |
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| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG0AJ8I |
| Policy instance | 1 |
| Insurance contract or identification number | GLUG0AJ8I | | Number of Individuals Covered | 103 | | Insurance policy start date | 2015-06-01 | | Insurance policy end date | 2016-05-31 | | Total amount of commissions paid to insurance broker | USD $1,334 | | Total amount of fees paid to insurance company | USD $453 | | 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 | AD&D | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $13,340 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,334 | | Amount paid for insurance broker fees | 453 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | RON FILICE ENTERPRISES, INC |
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| ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 ) |
| Policy contract number | 277891 |
| Policy instance | 2 |
| Insurance contract or identification number | 277891 | | Number of Individuals Covered | 240 | | Insurance policy start date | 2015-04-01 | | Insurance policy end date | 2016-03-31 | | Total amount of commissions paid to insurance broker | USD $44,415 | | Total amount of fees paid to insurance company | USD $21,501 | | 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 | 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 $1,006,099 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $44,415 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 21501 | | Additional information about fees paid to insurance broker | INCENTIVES, EDUCATION, COMMUNICATION AND/OR TRAINING | | Insurance broker name | CENTERSTONE INS & FINANCIAL SERVICE |
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| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
| Policy contract number | TS05912850 |
| Policy instance | 3 |
| Insurance contract or identification number | TS05912850 | | Number of Individuals Covered | 381 | | Insurance policy start date | 2015-06-01 | | Insurance policy end date | 2016-05-31 | | Total amount of commissions paid to insurance broker | USD $7,386 | | Total amount of fees paid to insurance company | USD $1,654 | | 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 $133,868 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,366 | | Amount paid for insurance broker fees | 1654 | | Additional information about fees paid to insurance broker | SUPPLEMENTAL COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | RON FILICE ENTERPRISES, INC |
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| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) |
| Policy contract number | TS05912850 |
| Policy instance | 3 |
| Insurance contract or identification number | TS05912850 | | Number of Individuals Covered | 386 | | Insurance policy start date | 2014-06-01 | | Insurance policy end date | 2015-05-31 | | Total amount of commissions paid to insurance broker | USD $7,806 | | Total amount of fees paid to insurance company | USD $6,469 | | 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 $121,426 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,861 | | Amount paid for insurance broker fees | 4595 | | Additional information about fees paid to insurance broker | SUPPLEMENTAL COMPENSATION & NON-MONETARY COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | CENTERSTONE INS. & FINANCIAL SVCS |
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| ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 ) |
| Policy contract number | 277891 |
| Policy instance | 2 |
| Insurance contract or identification number | 277891 | | Number of Individuals Covered | 249 | | Insurance policy start date | 2014-06-01 | | Insurance policy end date | 2015-05-31 | | Total amount of commissions paid to insurance broker | USD $38,701 | | Total amount of fees paid to insurance company | USD $19,176 | | 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 | 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 $907,804 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $38,701 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 19176 | | Additional information about fees paid to insurance broker | FEES PAID | | Insurance broker name | CENTERSTONE INS & FINANCIAL SERVICE |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG0AJ8I |
| Policy instance | 1 |
| Insurance contract or identification number | GLUG0AJ8I | | Number of Individuals Covered | 108 | | Insurance policy start date | 2014-06-01 | | Insurance policy end date | 2015-05-31 | | Total amount of commissions paid to insurance broker | USD $1,142 | | Total amount of fees paid to insurance company | USD $500 | | 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 | AD&D | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $11,420 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,142 | | Amount paid for insurance broker fees | 500 | | Additional information about fees paid to insurance broker | OTHER COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | FILICE INSURANCE AGENCY |
|
| ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 ) |
| Policy contract number | 277891 |
| Policy instance | 2 |
| Insurance contract or identification number | 277891 | | Number of Individuals Covered | 96 | | Insurance policy start date | 2013-06-01 | | Insurance policy end date | 2014-05-31 | | Total amount of commissions paid to insurance broker | USD $31,096 | | Total amount of fees paid to insurance company | USD $15,548 | | 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 $803,991 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $31,096 | | Insurance broker organization code? | 3 | | Amount paid for insurance broker fees | 15548 | | Additional information about fees paid to insurance broker | FEES PAID | | Insurance broker name | CENTERSTONE INS & FINANCIAL SERVICE |
|
| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) |
| Policy contract number | GLUG0AJ8I |
| Policy instance | 1 |
| Insurance contract or identification number | GLUG0AJ8I | | Number of Individuals Covered | 100 | | Insurance policy start date | 2013-06-01 | | Insurance policy end date | 2014-05-31 | | Total amount of commissions paid to insurance broker | USD $1,034 | | Total amount of fees paid to insurance company | USD $591 | | 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 | AD&D | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $10,341 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,034 | | Amount paid for insurance broker fees | 591 | | Additional information about fees paid to insurance broker | AGENT OR BROKER OF RECORD OTHER COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | FILICE INSURANCE AGENCY |
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