HEIN, PETE, ANDREW HETTINGA PTRS has sponsored the creation of one or more 401k plans.
| Measure | Date | Value |
|---|
| 2022: HETTINGA DAIRIES 2022 401k membership |
|---|
| Total participants, beginning-of-year | 2022-02-01 | 30 |
| Total number of active participants reported on line 7a of the Form 5500 | 2022-02-01 | 35 |
| Total of all active and inactive participants | 2022-02-01 | 35 |
| Total participants | 2022-02-01 | 35 |
| 2021: HETTINGA DAIRIES 2021 401k membership |
|---|
| Total participants, beginning-of-year | 2021-02-01 | 30 |
| Total number of active participants reported on line 7a of the Form 5500 | 2021-02-01 | 30 |
| Total of all active and inactive participants | 2021-02-01 | 30 |
| Total participants | 2021-02-01 | 30 |
| 2020: HETTINGA DAIRIES 2020 401k membership |
|---|
| Total participants, beginning-of-year | 2020-02-01 | 31 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-02-01 | 30 |
| Total of all active and inactive participants | 2020-02-01 | 30 |
| Total participants | 2020-02-01 | 30 |
| 2019: HETTINGA DAIRIES 2019 401k membership |
|---|
| Total participants, beginning-of-year | 2019-02-01 | 38 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-02-01 | 31 |
| Total of all active and inactive participants | 2019-02-01 | 31 |
| Total participants | 2019-02-01 | 31 |
| 2018: HETTINGA DAIRIES 2018 401k membership |
|---|
| Total participants, beginning-of-year | 2018-02-01 | 38 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-02-01 | 38 |
| Total of all active and inactive participants | 2018-02-01 | 38 |
| Total participants | 2018-02-01 | 38 |
| 2017: HETTINGA DAIRIES 2017 401k membership |
|---|
| Total participants, beginning-of-year | 2017-02-01 | 38 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-02-01 | 38 |
| Total of all active and inactive participants | 2017-02-01 | 38 |
| Total participants | 2017-02-01 | 38 |
| 2016: HETTINGA DAIRIES 2016 401k membership |
|---|
| Total participants, beginning-of-year | 2016-02-01 | 31 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-02-01 | 38 |
| Total of all active and inactive participants | 2016-02-01 | 38 |
| Total participants | 2016-02-01 | 38 |
| 2015: HETTINGA DAIRIES 2015 401k membership |
|---|
| Total participants, beginning-of-year | 2015-02-01 | 37 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-02-01 | 31 |
| Number of retired or separated participants receiving benefits | 2015-02-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2015-02-01 | 0 |
| Total of all active and inactive participants | 2015-02-01 | 31 |
| Total participants | 2015-02-01 | 31 |
| 2022: HETTINGA DAIRIES 2022 form 5500 responses |
|---|
| 2022-02-01 | Type of plan entity | Single employer plan |
| 2022-02-01 | Submission has been amended | No |
| 2022-02-01 | This submission is the final filing | No |
| 2022-02-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2022-02-01 | Plan is a collectively bargained plan | No |
| 2022-02-01 | Plan funding arrangement – Insurance | Yes |
| 2022-02-01 | Plan benefit arrangement – Insurance | Yes |
| 2021: HETTINGA DAIRIES 2021 form 5500 responses |
|---|
| 2021-02-01 | Type of plan entity | Single employer plan |
| 2021-02-01 | Submission has been amended | No |
| 2021-02-01 | This submission is the final filing | No |
| 2021-02-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2021-02-01 | Plan is a collectively bargained plan | No |
| 2021-02-01 | Plan funding arrangement – Insurance | Yes |
| 2021-02-01 | Plan benefit arrangement – Insurance | Yes |
| 2020: HETTINGA DAIRIES 2020 form 5500 responses |
|---|
| 2020-02-01 | Type of plan entity | Single employer plan |
| 2020-02-01 | Submission has been amended | No |
| 2020-02-01 | This submission is the final filing | No |
| 2020-02-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2020-02-01 | Plan is a collectively bargained plan | No |
| 2020-02-01 | Plan funding arrangement – Insurance | Yes |
| 2020-02-01 | Plan benefit arrangement – Insurance | Yes |
| 2019: HETTINGA DAIRIES 2019 form 5500 responses |
|---|
| 2019-02-01 | Type of plan entity | Single employer plan |
| 2019-02-01 | Submission has been amended | No |
| 2019-02-01 | This submission is the final filing | No |
| 2019-02-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2019-02-01 | Plan is a collectively bargained plan | No |
| 2019-02-01 | Plan funding arrangement – Insurance | Yes |
| 2019-02-01 | Plan benefit arrangement – Insurance | Yes |
| 2018: HETTINGA DAIRIES 2018 form 5500 responses |
|---|
| 2018-02-01 | Type of plan entity | Single employer plan |
| 2018-02-01 | Submission has been amended | No |
| 2018-02-01 | This submission is the final filing | No |
| 2018-02-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2018-02-01 | Plan is a collectively bargained plan | No |
| 2018-02-01 | Plan funding arrangement – Insurance | Yes |
| 2018-02-01 | Plan benefit arrangement – Insurance | Yes |
| 2017: HETTINGA DAIRIES 2017 form 5500 responses |
|---|
| 2017-02-01 | Type of plan entity | Single employer plan |
| 2017-02-01 | Submission has been amended | No |
| 2017-02-01 | This submission is the final filing | No |
| 2017-02-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2017-02-01 | Plan is a collectively bargained plan | No |
| 2017-02-01 | Plan funding arrangement – Insurance | Yes |
| 2017-02-01 | Plan benefit arrangement – Insurance | Yes |
| 2016: HETTINGA DAIRIES 2016 form 5500 responses |
|---|
| 2016-02-01 | Type of plan entity | Single employer plan |
| 2016-02-01 | Submission has been amended | No |
| 2016-02-01 | This submission is the final filing | No |
| 2016-02-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2016-02-01 | Plan is a collectively bargained plan | No |
| 2016-02-01 | Plan funding arrangement – Insurance | Yes |
| 2016-02-01 | Plan benefit arrangement – Insurance | Yes |
| 2015: HETTINGA DAIRIES 2015 form 5500 responses |
|---|
| 2015-02-01 | Type of plan entity | Single employer plan |
| 2015-02-01 | First time form 5500 has been submitted | Yes |
| 2015-02-01 | Submission has been amended | No |
| 2015-02-01 | This submission is the final filing | No |
| 2015-02-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2015-02-01 | Plan is a collectively bargained plan | No |
| 2015-02-01 | Plan funding arrangement – Insurance | Yes |
| 2015-02-01 | Plan benefit arrangement – Insurance | Yes |
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 904746 |
| Policy instance | 2 |
| Insurance contract or identification number | 904746 | | Number of Individuals Covered | 35 | | Insurance policy start date | 2022-02-01 | | Insurance policy end date | 2023-01-31 | | Total amount of fees paid to insurance company | USD $6,428 | | 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 $123,401 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 6428 | | Additional information about fees paid to insurance broker | SERVICE FEE AGREEMENT | | Insurance broker organization code? | 3 |
|
| AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 ) |
| Policy contract number | 82-2723296 |
| Policy instance | 1 |
| Insurance contract or identification number | 82-2723296 | | Number of Individuals Covered | 15 | | Insurance policy start date | 2022-02-01 | | Insurance policy end date | 2023-01-31 | | Total amount of commissions paid to insurance broker | USD $2,112 | | 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 | Yes | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | CANCER, LUMP SUM CRITICAL ILLNESS, SPECIAL EVENT | | 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 $9,481 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $592 |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 0904746 |
| Policy instance | 2 |
| Insurance contract or identification number | 0904746 | | Number of Individuals Covered | 30 | | Insurance policy start date | 2021-02-01 | | Insurance policy end date | 2022-01-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $6,042 | | 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 $124,873 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $0 | | Amount paid for insurance broker fees | 6042 | | Additional information about fees paid to insurance broker | SERVICE FEE AGREEMENT | | Insurance broker organization code? | 3 |
|
| AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 ) |
| Policy contract number | 82-2723296 |
| Policy instance | 1 |
| Insurance contract or identification number | 82-2723296 | | Number of Individuals Covered | 18 | | Insurance policy start date | 2021-02-01 | | Insurance policy end date | 2022-01-31 | | Total amount of commissions paid to insurance broker | USD $922 | | Total amount of fees paid to insurance company | USD $25 | | 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 | Yes | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | CANCER, LUMP SUM CRITICAL ILLNESS, SPECIAL EVENT | | Were dividends or retroactive rate refunds paid in cash? | No | | Were dividends or retroactive rate refunds paid as a credit? | No | | Welfare Benefit Premiums Paid to Carrier | USD $7,950 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $306 | | Amount paid for insurance broker fees | 16 | | Additional information about fees paid to insurance broker | FEES PAID |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 0904746 |
| Policy instance | 2 |
| Insurance contract or identification number | 0904746 | | Number of Individuals Covered | 30 | | Insurance policy start date | 2020-02-01 | | Insurance policy end date | 2021-01-31 | | Total amount of fees paid to insurance company | USD $6,212 | | 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 $118,397 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $0 | | Amount paid for insurance broker fees | 6212 | | Additional information about fees paid to insurance broker | SERVICE FEE AGREEMENT | | Insurance broker organization code? | 3 |
|
| AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 ) |
| Policy contract number | 82-2723296 |
| Policy instance | 1 |
| Insurance contract or identification number | 82-2723296 | | Number of Individuals Covered | 23 | | Insurance policy start date | 2020-02-01 | | Insurance policy end date | 2021-01-31 | | Total amount of commissions paid to insurance broker | USD $1,663 | | Total amount of fees paid to insurance company | USD $46 | | 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 | Yes | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | CANCER, LUMP SUM CRITICAL ILLNESS, SPECIAL EVENT | | 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 $12,176 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $559 | | Amount paid for insurance broker fees | 0 |
|
| AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 ) |
| Policy contract number | 82-2723296 |
| Policy instance | 2 |
| Insurance contract or identification number | 82-2723296 | | Number of Individuals Covered | 32 | | Insurance policy start date | 2019-02-01 | | Insurance policy end date | 2020-01-31 | | Total amount of commissions paid to insurance broker | USD $4,306 | | Total amount of fees paid to insurance company | USD $488 | | 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 | Yes | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | CANCER, LUMP SUM CRITICAL ILLNESS, SPECIAL EVENT | | 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 $13,945 | | 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 | | Amount paid for insurance broker fees | 0 |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 0904746 |
| Policy instance | 1 |
| Insurance contract or identification number | 0904746 | | Number of Individuals Covered | 31 | | Insurance policy start date | 2019-02-01 | | Insurance policy end date | 2020-01-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $7,769 | | 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 $116,974 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $0 | | Amount paid for insurance broker fees | 7769 | | Additional information about fees paid to insurance broker | SERVICE FEE AGREEMENT | | Insurance broker organization code? | 3 |
|
| AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 ) |
| Policy contract number | 82-2723296 |
| Policy instance | 3 |
| Insurance contract or identification number | 82-2723296 | | Number of Individuals Covered | 7 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $730 | | 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 | Yes | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | No | | Unemployment Insurance Welfare Benefit | No | | Other welfare benefits provided | CANCER, LUMP SUM CRITICAL ILLNESS, SPECIAL EVENT | | 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 $1,617 | | 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 | | Amount paid for insurance broker fees | 0 |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 0904746 |
| Policy instance | 2 |
| Insurance contract or identification number | 0904746 | | Number of Individuals Covered | 38 | | Insurance policy start date | 2018-02-01 | | Insurance policy end date | 2019-01-31 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $4,935 | | 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 $103,142 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $0 | | Amount paid for insurance broker fees | 4935 | | Additional information about fees paid to insurance broker | SERVICE FEE AGREEMENT | | Insurance broker organization code? | 3 |
|
| COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 ) |
| Policy contract number | E4401105 |
| Policy instance | 1 |
| Insurance contract or identification number | E4401105 | | Number of Individuals Covered | 0 | | Insurance policy start date | 2018-02-01 | | Insurance policy end date | 2019-01-31 | | Total amount of commissions paid to insurance broker | USD $1,270 | | Total amount of fees paid to insurance company | USD $158 | | 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 | 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 $6,023 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $91 | | Amount paid for insurance broker fees | 0 | | Insurance broker organization code? | 3 |
|
| COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 ) |
| Policy contract number | E4401105 |
| Policy instance | 2 |
| Insurance contract or identification number | E4401105 | | Number of Individuals Covered | 19 | | Insurance policy start date | 2017-02-01 | | Insurance policy end date | 2018-01-31 | | Total amount of commissions paid to insurance broker | USD $2,110 | | Total amount of fees paid to insurance company | USD $805 | | 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 | 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 $9,851 | | 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 | | Amount paid for insurance broker fees | 0 | | Additional information about fees paid to insurance broker | SERVICE FEES | | Insurance broker organization code? | 3 | | Insurance broker name | HELEN RODRIGUEZ-BURTON |
|
| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 0904746 |
| Policy instance | 1 |
| Insurance contract or identification number | 0904746 | | Number of Individuals Covered | 38 | | Insurance policy start date | 2017-02-01 | | Insurance policy end date | 2018-01-31 | | Total amount of fees paid to insurance company | USD $4,366 | | 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 $83,207 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 4366 | | Additional information about fees paid to insurance broker | SERVICE FEE AGREEMENT | | Insurance broker organization code? | 3 | | Insurance broker name | FAIRLY CONSULTING GROUP LLC |
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| UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 ) |
| Policy contract number | 904746 |
| Policy instance | 2 |
| Insurance contract or identification number | 904746 | | Number of Individuals Covered | 31 | | Insurance policy start date | 2015-02-01 | | Insurance policy end date | 2016-01-31 | | Total amount of fees paid to insurance company | USD $4,461 | | 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 $93,049 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 4461 | | Additional information about fees paid to insurance broker | SERVICE FEE AGREEMENT | | Insurance broker organization code? | 3 | | Insurance broker name | WILLIS OF TEXAS, INC |
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| COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 ) |
| Policy contract number | E4401105 |
| Policy instance | 1 |
| Insurance contract or identification number | E4401105 | | Number of Individuals Covered | 21 | | Insurance policy start date | 2015-02-01 | | Insurance policy end date | 2016-01-31 | | Total amount of commissions paid to insurance broker | USD $5,286 | | Total amount of fees paid to insurance company | USD $1,750 | | 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 $8,881 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $516 | | Amount paid for insurance broker fees | 25 | | Additional information about fees paid to insurance broker | SERVICE FEES | | Insurance broker organization code? | 3 | | Insurance broker name | WILLIS OF TEXAS, INC |
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