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HEALTH BENEFIT PLAN FOR EMPLOYEES OF COMMUNITY HOSPITAL AND NURSING HOME OF ANACONDA 401k Plan overview

Plan NameHEALTH BENEFIT PLAN FOR EMPLOYEES OF COMMUNITY HOSPITAL AND NURSING HOME OF ANACONDA
Plan identification number 501

HEALTH BENEFIT PLAN FOR EMPLOYEES OF COMMUNITY HOSPITAL AND NURSING HOME OF ANACONDA Benefits

401k Plan TypeWelfare Benefit
Plan Features/Benefits
  • Health (other than dental or vision)
  • Life insurance

401k Sponsoring company profile

COMMUNITY HOSPITAL OF ANACONDA has sponsored the creation of one or more 401k plans.

Company Name:COMMUNITY HOSPITAL OF ANACONDA
Employer identification number (EIN):810303913
NAIC Classification:622000
NAIC Description: Hospitals

Form 5500 Filing Information

Submission information for form 5500 for 401k plan HEALTH BENEFIT PLAN FOR EMPLOYEES OF COMMUNITY HOSPITAL AND NURSING HOME OF ANACONDA

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5012022-01-01
5012021-01-01
5012020-01-01
5012019-01-01
5012018-01-01MARGARET HICKEY-BOYNTON
5012017-01-01MARGARET HICKEY-BOYNTON
5012016-04-01MARGARET HICKEY-BOYNTON
5012015-04-01MARGARET HICKEY-BOYNTON
5012014-04-01MARGARET HICKEY-BOYNTON
5012013-04-01MARGARET HICKEY-BOYNTON
5012012-04-01MARGARET HICKEY-BOYNTON
5012011-04-01MARGARET HICKEY-BOYNTON
5012010-04-01MARGARET HICKEY-BOYNTON
5012009-04-01MARGARET HICKEY-BOYNTON MARGARET HICKEY-BOYNTON2010-12-07

Plan Statistics for HEALTH BENEFIT PLAN FOR EMPLOYEES OF COMMUNITY HOSPITAL AND NURSING HOME OF ANACONDA

401k plan membership statisitcs for HEALTH BENEFIT PLAN FOR EMPLOYEES OF COMMUNITY HOSPITAL AND NURSING HOME OF ANACONDA

Measure Date Value
2022: HEALTH BENEFIT PLAN FOR EMPLOYEES OF COMMUNITY HOSPITAL AND NURSING HOME OF ANACONDA 2022 401k membership
Total participants, beginning-of-year2022-01-01548
Total number of active participants reported on line 7a of the Form 55002022-01-01550
Number of retired or separated participants receiving benefits2022-01-010
Number of other retired or separated participants entitled to future benefits2022-01-010
Total of all active and inactive participants2022-01-01550
2021: HEALTH BENEFIT PLAN FOR EMPLOYEES OF COMMUNITY HOSPITAL AND NURSING HOME OF ANACONDA 2021 401k membership
Total participants, beginning-of-year2021-01-01534
Total number of active participants reported on line 7a of the Form 55002021-01-01548
Number of retired or separated participants receiving benefits2021-01-010
Number of other retired or separated participants entitled to future benefits2021-01-010
Total of all active and inactive participants2021-01-01548
2020: HEALTH BENEFIT PLAN FOR EMPLOYEES OF COMMUNITY HOSPITAL AND NURSING HOME OF ANACONDA 2020 401k membership
Total participants, beginning-of-year2020-01-01540
Total number of active participants reported on line 7a of the Form 55002020-01-01534
Number of retired or separated participants receiving benefits2020-01-010
Number of other retired or separated participants entitled to future benefits2020-01-010
Total of all active and inactive participants2020-01-01534
2019: HEALTH BENEFIT PLAN FOR EMPLOYEES OF COMMUNITY HOSPITAL AND NURSING HOME OF ANACONDA 2019 401k membership
Total participants, beginning-of-year2019-01-01511
Total number of active participants reported on line 7a of the Form 55002019-01-01540
Number of retired or separated participants receiving benefits2019-01-010
Number of other retired or separated participants entitled to future benefits2019-01-010
Total of all active and inactive participants2019-01-01540
2018: HEALTH BENEFIT PLAN FOR EMPLOYEES OF COMMUNITY HOSPITAL AND NURSING HOME OF ANACONDA 2018 401k membership
Total participants, beginning-of-year2018-01-01489
Total number of active participants reported on line 7a of the Form 55002018-01-01511
Number of retired or separated participants receiving benefits2018-01-010
Number of other retired or separated participants entitled to future benefits2018-01-010
Total of all active and inactive participants2018-01-01511
2017: HEALTH BENEFIT PLAN FOR EMPLOYEES OF COMMUNITY HOSPITAL AND NURSING HOME OF ANACONDA 2017 401k membership
Total participants, beginning-of-year2017-01-01386
Total number of active participants reported on line 7a of the Form 55002017-01-01489
Number of retired or separated participants receiving benefits2017-01-010
Number of other retired or separated participants entitled to future benefits2017-01-010
Total of all active and inactive participants2017-01-01489
2016: HEALTH BENEFIT PLAN FOR EMPLOYEES OF COMMUNITY HOSPITAL AND NURSING HOME OF ANACONDA 2016 401k membership
Total participants, beginning-of-year2016-04-01247
Total number of active participants reported on line 7a of the Form 55002016-04-01386
Number of retired or separated participants receiving benefits2016-04-010
Number of other retired or separated participants entitled to future benefits2016-04-010
Total of all active and inactive participants2016-04-01386
2015: HEALTH BENEFIT PLAN FOR EMPLOYEES OF COMMUNITY HOSPITAL AND NURSING HOME OF ANACONDA 2015 401k membership
Total participants, beginning-of-year2015-04-01241
Total number of active participants reported on line 7a of the Form 55002015-04-01247
Number of retired or separated participants receiving benefits2015-04-010
Number of other retired or separated participants entitled to future benefits2015-04-010
Total of all active and inactive participants2015-04-01247
2014: HEALTH BENEFIT PLAN FOR EMPLOYEES OF COMMUNITY HOSPITAL AND NURSING HOME OF ANACONDA 2014 401k membership
Total participants, beginning-of-year2014-04-01231
Total number of active participants reported on line 7a of the Form 55002014-04-01241
Number of retired or separated participants receiving benefits2014-04-010
Number of other retired or separated participants entitled to future benefits2014-04-010
Total of all active and inactive participants2014-04-01241
2013: HEALTH BENEFIT PLAN FOR EMPLOYEES OF COMMUNITY HOSPITAL AND NURSING HOME OF ANACONDA 2013 401k membership
Total participants, beginning-of-year2013-04-01220
Total number of active participants reported on line 7a of the Form 55002013-04-01231
Number of retired or separated participants receiving benefits2013-04-010
Number of other retired or separated participants entitled to future benefits2013-04-010
Total of all active and inactive participants2013-04-01231
Total participants2013-04-01231
2012: HEALTH BENEFIT PLAN FOR EMPLOYEES OF COMMUNITY HOSPITAL AND NURSING HOME OF ANACONDA 2012 401k membership
Total participants, beginning-of-year2012-04-01214
Total number of active participants reported on line 7a of the Form 55002012-04-01220
Total of all active and inactive participants2012-04-01220
2011: HEALTH BENEFIT PLAN FOR EMPLOYEES OF COMMUNITY HOSPITAL AND NURSING HOME OF ANACONDA 2011 401k membership
Total participants, beginning-of-year2011-04-01206
Total number of active participants reported on line 7a of the Form 55002011-04-01214
Total of all active and inactive participants2011-04-01214
2010: HEALTH BENEFIT PLAN FOR EMPLOYEES OF COMMUNITY HOSPITAL AND NURSING HOME OF ANACONDA 2010 401k membership
Total participants, beginning-of-year2010-04-01194
Total number of active participants reported on line 7a of the Form 55002010-04-01206
Total of all active and inactive participants2010-04-01206
2009: HEALTH BENEFIT PLAN FOR EMPLOYEES OF COMMUNITY HOSPITAL AND NURSING HOME OF ANACONDA 2009 401k membership
Total participants, beginning-of-year2009-04-01187
Total number of active participants reported on line 7a of the Form 55002009-04-01194
Total of all active and inactive participants2009-04-01194

Form 5500 Responses for HEALTH BENEFIT PLAN FOR EMPLOYEES OF COMMUNITY HOSPITAL AND NURSING HOME OF ANACONDA

2022: HEALTH BENEFIT PLAN FOR EMPLOYEES OF COMMUNITY HOSPITAL AND NURSING HOME OF ANACONDA 2022 form 5500 responses
2022-01-01Type of plan entitySingle employer plan
2022-01-01Plan funding arrangement – InsuranceYes
2022-01-01Plan funding arrangement – General assets of the sponsorYes
2022-01-01Plan benefit arrangement – InsuranceYes
2022-01-01Plan benefit arrangement – General assets of the sponsorYes
2021: HEALTH BENEFIT PLAN FOR EMPLOYEES OF COMMUNITY HOSPITAL AND NURSING HOME OF ANACONDA 2021 form 5500 responses
2021-01-01Type of plan entitySingle employer plan
2021-01-01Plan funding arrangement – InsuranceYes
2021-01-01Plan funding arrangement – General assets of the sponsorYes
2021-01-01Plan benefit arrangement – InsuranceYes
2021-01-01Plan benefit arrangement – General assets of the sponsorYes
2020: HEALTH BENEFIT PLAN FOR EMPLOYEES OF COMMUNITY HOSPITAL AND NURSING HOME OF ANACONDA 2020 form 5500 responses
2020-01-01Type of plan entitySingle employer plan
2020-01-01Plan funding arrangement – InsuranceYes
2020-01-01Plan funding arrangement – General assets of the sponsorYes
2020-01-01Plan benefit arrangement – InsuranceYes
2020-01-01Plan benefit arrangement – General assets of the sponsorYes
2019: HEALTH BENEFIT PLAN FOR EMPLOYEES OF COMMUNITY HOSPITAL AND NURSING HOME OF ANACONDA 2019 form 5500 responses
2019-01-01Type of plan entitySingle employer plan
2019-01-01Plan funding arrangement – InsuranceYes
2019-01-01Plan funding arrangement – General assets of the sponsorYes
2019-01-01Plan benefit arrangement – InsuranceYes
2019-01-01Plan benefit arrangement – General assets of the sponsorYes
2018: HEALTH BENEFIT PLAN FOR EMPLOYEES OF COMMUNITY HOSPITAL AND NURSING HOME OF ANACONDA 2018 form 5500 responses
2018-01-01Type of plan entitySingle employer plan
2018-01-01Plan funding arrangement – InsuranceYes
2018-01-01Plan funding arrangement – General assets of the sponsorYes
2018-01-01Plan benefit arrangement – InsuranceYes
2018-01-01Plan benefit arrangement – General assets of the sponsorYes
2017: HEALTH BENEFIT PLAN FOR EMPLOYEES OF COMMUNITY HOSPITAL AND NURSING HOME OF ANACONDA 2017 form 5500 responses
2017-01-01Type of plan entitySingle employer plan
2017-01-01Plan funding arrangement – InsuranceYes
2017-01-01Plan funding arrangement – General assets of the sponsorYes
2017-01-01Plan benefit arrangement – InsuranceYes
2017-01-01Plan benefit arrangement – General assets of the sponsorYes
2016: HEALTH BENEFIT PLAN FOR EMPLOYEES OF COMMUNITY HOSPITAL AND NURSING HOME OF ANACONDA 2016 form 5500 responses
2016-04-01Type of plan entitySingle employer plan
2016-04-01This return/report is a short plan year return/report (less than 12 months)Yes
2016-04-01Plan funding arrangement – InsuranceYes
2016-04-01Plan funding arrangement – General assets of the sponsorYes
2016-04-01Plan benefit arrangement – InsuranceYes
2016-04-01Plan benefit arrangement – General assets of the sponsorYes
2015: HEALTH BENEFIT PLAN FOR EMPLOYEES OF COMMUNITY HOSPITAL AND NURSING HOME OF ANACONDA 2015 form 5500 responses
2015-04-01Type of plan entitySingle employer plan
2015-04-01Plan funding arrangement – InsuranceYes
2015-04-01Plan funding arrangement – General assets of the sponsorYes
2015-04-01Plan benefit arrangement – InsuranceYes
2015-04-01Plan benefit arrangement – General assets of the sponsorYes
2014: HEALTH BENEFIT PLAN FOR EMPLOYEES OF COMMUNITY HOSPITAL AND NURSING HOME OF ANACONDA 2014 form 5500 responses
2014-04-01Type of plan entitySingle employer plan
2014-04-01Plan funding arrangement – InsuranceYes
2014-04-01Plan funding arrangement – General assets of the sponsorYes
2014-04-01Plan benefit arrangement – InsuranceYes
2014-04-01Plan benefit arrangement – General assets of the sponsorYes
2013: HEALTH BENEFIT PLAN FOR EMPLOYEES OF COMMUNITY HOSPITAL AND NURSING HOME OF ANACONDA 2013 form 5500 responses
2013-04-01Type of plan entitySingle employer plan
2013-04-01Plan funding arrangement – InsuranceYes
2013-04-01Plan funding arrangement – General assets of the sponsorYes
2013-04-01Plan benefit arrangement – InsuranceYes
2013-04-01Plan benefit arrangement – General assets of the sponsorYes
2012: HEALTH BENEFIT PLAN FOR EMPLOYEES OF COMMUNITY HOSPITAL AND NURSING HOME OF ANACONDA 2012 form 5500 responses
2012-04-01Type of plan entitySingle employer plan
2012-04-01Plan funding arrangement – InsuranceYes
2012-04-01Plan funding arrangement – General assets of the sponsorYes
2012-04-01Plan benefit arrangement – InsuranceYes
2012-04-01Plan benefit arrangement – General assets of the sponsorYes
2011: HEALTH BENEFIT PLAN FOR EMPLOYEES OF COMMUNITY HOSPITAL AND NURSING HOME OF ANACONDA 2011 form 5500 responses
2011-04-01Type of plan entitySingle employer plan
2011-04-01Submission has been amendedNo
2011-04-01This submission is the final filingNo
2011-04-01This return/report is a short plan year return/report (less than 12 months)No
2011-04-01Plan is a collectively bargained planNo
2011-04-01Plan funding arrangement – InsuranceYes
2011-04-01Plan funding arrangement – General assets of the sponsorYes
2011-04-01Plan benefit arrangement – InsuranceYes
2011-04-01Plan benefit arrangement – General assets of the sponsorYes
2010: HEALTH BENEFIT PLAN FOR EMPLOYEES OF COMMUNITY HOSPITAL AND NURSING HOME OF ANACONDA 2010 form 5500 responses
2010-04-01Type of plan entitySingle employer plan
2010-04-01Submission has been amendedNo
2010-04-01This submission is the final filingNo
2010-04-01This return/report is a short plan year return/report (less than 12 months)No
2010-04-01Plan is a collectively bargained planNo
2010-04-01Plan funding arrangement – InsuranceYes
2010-04-01Plan funding arrangement – General assets of the sponsorYes
2010-04-01Plan benefit arrangement – InsuranceYes
2010-04-01Plan benefit arrangement – General assets of the sponsorYes
2009: HEALTH BENEFIT PLAN FOR EMPLOYEES OF COMMUNITY HOSPITAL AND NURSING HOME OF ANACONDA 2009 form 5500 responses
2009-04-01Type of plan entitySingle employer plan
2009-04-01Submission has been amendedNo
2009-04-01This submission is the final filingNo
2009-04-01This return/report is a short plan year return/report (less than 12 months)No
2009-04-01Plan is a collectively bargained planNo
2009-04-01Plan funding arrangement – InsuranceYes
2009-04-01Plan funding arrangement – General assets of the sponsorYes
2009-04-01Plan benefit arrangement – InsuranceYes
2009-04-01Plan benefit arrangement – General assets of the sponsorYes

Insurance Providers Used on plan

BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )
Policy contract number195383
Policy instance 3
Insurance contract or identification number195383
Number of Individuals Covered550
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $78,570
Total amount of fees paid to insurance companyUSD $13,144
Health Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $78,570
Amount paid for insurance broker fees13144
Additional information about fees paid to insurance brokerVOLUME BASED COMMISSION
Insurance broker organization code?3
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number30073037
Policy instance 2
Insurance contract or identification number30073037
Number of Individuals Covered133
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $1,332
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $19,417
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,088
Additional information about fees paid to insurance brokerN/A
Insurance broker organization code?3
STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )
Policy contract number160799
Policy instance 1
Insurance contract or identification number160799
Number of Individuals Covered356
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $11,431
Life Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $10,241
Additional information about fees paid to insurance brokerN/A
Insurance broker organization code?3
BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )
Policy contract number195383
Policy instance 3
Insurance contract or identification number195383
Number of Individuals Covered548
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $75,459
Total amount of fees paid to insurance companyUSD $9,216
Health Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $75,459
Amount paid for insurance broker fees9216
Additional information about fees paid to insurance brokerVOLUME BASED COMMISSION
Insurance broker organization code?3
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number30073037
Policy instance 2
Insurance contract or identification number30073037
Number of Individuals Covered135
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $1,320
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $19,618
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,095
Additional information about fees paid to insurance brokerN/A
Insurance broker organization code?3
STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )
Policy contract number160799
Policy instance 1
Insurance contract or identification number160799
Number of Individuals Covered353
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $9,967
Life Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $8,828
Additional information about fees paid to insurance brokerN/A
Insurance broker organization code?3
STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )
Policy contract number160799
Policy instance 1
Insurance contract or identification number160799
Number of Individuals Covered362
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $10,711
Life Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $9,440
Additional information about fees paid to insurance brokerN/A
Insurance broker organization code?3
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number30073037
Policy instance 2
Insurance contract or identification number30073037
Number of Individuals Covered131
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $1,053
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $18,483
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,053
BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )
Policy contract number195383
Policy instance 3
Insurance contract or identification number195383
Number of Individuals Covered534
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $75,292
Health Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $75,292
Additional information about fees paid to insurance brokerN/A
Insurance broker organization code?3
BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )
Policy contract number195383
Policy instance 3
Insurance contract or identification number195383
Number of Individuals Covered540
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $76,335
Health Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $76,335
Additional information about fees paid to insurance brokerN/A
Insurance broker organization code?3
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number30073037
Policy instance 2
Insurance contract or identification number30073037
Number of Individuals Covered70
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $607
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $8,609
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $607
STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )
Policy contract number160799
Policy instance 1
Insurance contract or identification number160799
Number of Individuals Covered379
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $10,030
Life Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $9,156
Additional information about fees paid to insurance brokerN/A
Insurance broker organization code?3
BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )
Policy contract number195383
Policy instance 3
Insurance contract or identification number195383
Number of Individuals Covered511
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $74,493
Health Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $74,493
Additional information about fees paid to insurance brokerN/A
Insurance broker organization code?3
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number30073037
Policy instance 2
Insurance contract or identification number30073037
Number of Individuals Covered62
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $587
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $6,745
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $587
STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )
Policy contract number160799
Policy instance 1
Insurance contract or identification number160799
Number of Individuals Covered361
Insurance policy start date2018-01-01
Insurance policy end date2018-12-31
Total amount of commissions paid to insurance brokerUSD $13,829
Life Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $12,811
Additional information about fees paid to insurance brokerN/A
Insurance broker organization code?3
BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )
Policy contract number195383
Policy instance 3
Insurance contract or identification number195383
Number of Individuals Covered489
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $47,775
Health Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $47,775
Additional information about fees paid to insurance brokerN/A
Insurance broker organization code?3
Insurance broker nameGALLAGHER BENEFIT SERVICES, INC.
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )
Policy contract number30073037
Policy instance 2
Insurance contract or identification number30073037
Number of Individuals Covered51
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $511
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $5,221
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $511
Insurance broker nameDANELLE M ADAMS
STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )
Policy contract number160799
Policy instance 1
Insurance contract or identification number160799
Number of Individuals Covered363
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $4,950
Life Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,985
Additional information about fees paid to insurance brokerN/A
Insurance broker organization code?3
Insurance broker nameGALLAGHER BENEFIT SERVICES
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number148509
Policy instance 1
Insurance contract or identification number148509
Number of Individuals Covered247
Insurance policy start date2015-04-01
Insurance policy end date2016-01-01
Total amount of commissions paid to insurance brokerUSD $1,441
Total amount of fees paid to insurance companyUSD $192
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Other welfare benefits providedADD
Welfare Benefit Premiums Paid to CarrierUSD $15,415
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,441
Amount paid for insurance broker fees192
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
Insurance broker organization code?3
Insurance broker nameGALLAGHER BENEFIT SERVICES INC.
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number148510
Policy instance 2
Insurance contract or identification number148510
Number of Individuals Covered66
Insurance policy start date2015-04-01
Insurance policy end date2016-03-31
Total amount of commissions paid to insurance brokerUSD $3,188
Total amount of fees paid to insurance companyUSD $266
Other welfare benefits providedLIFESTYLE ADD; LIFESTYLE
Welfare Benefit Premiums Paid to CarrierUSD $21,099
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,188
Amount paid for insurance broker fees266
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
Insurance broker organization code?3
Insurance broker nameGALLAGHER BENEFIT SERVICES INC.
STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )
Policy contract number160799
Policy instance 3
Insurance contract or identification number160799
Number of Individuals Covered320
Insurance policy start date2016-01-01
Insurance policy end date2016-03-31
Life Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number148510
Policy instance 2
Insurance contract or identification number148510
Number of Individuals Covered68
Insurance policy start date2014-04-01
Insurance policy end date2015-03-31
Total amount of commissions paid to insurance brokerUSD $3,647
Total amount of fees paid to insurance companyUSD $304
Other welfare benefits providedLIFESTYLE ADD; LIFESTYLE
Welfare Benefit Premiums Paid to CarrierUSD $24,320
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,647
Amount paid for insurance broker fees304
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
Insurance broker organization code?3
Insurance broker nameGALLAGHER BENEFIT SERVICES INC.
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number148509
Policy instance 1
Insurance contract or identification number148509
Number of Individuals Covered241
Insurance policy start date2014-04-01
Insurance policy end date2015-03-31
Total amount of commissions paid to insurance brokerUSD $1,859
Total amount of fees paid to insurance companyUSD $252
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Other welfare benefits providedADD
Welfare Benefit Premiums Paid to CarrierUSD $20,129
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,859
Amount paid for insurance broker fees252
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
Insurance broker organization code?3
Insurance broker nameGALLAGHER BENEFIT SERVICES INC.
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number148510
Policy instance 2
Insurance contract or identification number148510
Number of Individuals Covered68
Insurance policy start date2013-04-01
Insurance policy end date2014-03-31
Total amount of commissions paid to insurance brokerUSD $3,374
Total amount of fees paid to insurance companyUSD $281
Other welfare benefits providedLIFESTYLE ADD; LIFESTYLE
Welfare Benefit Premiums Paid to CarrierUSD $22,495
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,374
Amount paid for insurance broker fees281
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
Insurance broker organization code?3
Insurance broker nameGALLAGHER BENEFIT SERVICES INC.
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number148509
Policy instance 1
Insurance contract or identification number148509
Number of Individuals Covered231
Insurance policy start date2013-04-01
Insurance policy end date2014-03-31
Total amount of commissions paid to insurance brokerUSD $1,775
Total amount of fees paid to insurance companyUSD $237
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Other welfare benefits providedADD
Welfare Benefit Premiums Paid to CarrierUSD $18,929
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,775
Amount paid for insurance broker fees237
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
Insurance broker organization code?3
Insurance broker nameGALLAGHER BENEFIT SERVICES INC.
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number148510
Policy instance 2
Insurance contract or identification number148510
Number of Individuals Covered68
Insurance policy start date2012-04-01
Insurance policy end date2013-03-31
Total amount of commissions paid to insurance brokerUSD $3,544
Total amount of fees paid to insurance companyUSD $295
Other welfare benefits providedLIFESTYLE ADD; LIFESTYLE
Welfare Benefit Premiums Paid to CarrierUSD $23,626
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,544
Amount paid for insurance broker fees295
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
Insurance broker organization code?3
Insurance broker nameGALLAGHER BENEFIT SERVICES INC.
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number148509
Policy instance 1
Insurance contract or identification number148509
Number of Individuals Covered220
Insurance policy start date2012-04-01
Insurance policy end date2013-03-31
Total amount of commissions paid to insurance brokerUSD $1,768
Total amount of fees paid to insurance companyUSD $235
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Other welfare benefits providedADD
Welfare Benefit Premiums Paid to CarrierUSD $18,829
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,768
Amount paid for insurance broker fees235
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
Insurance broker organization code?3
Insurance broker nameGALLAGHER BENEFIT SERVICES INC.
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number148509
Policy instance 2
Insurance contract or identification number148509
Number of Individuals Covered214
Insurance policy start date2011-04-01
Insurance policy end date2012-03-31
Total amount of commissions paid to insurance brokerUSD $1,720
Total amount of fees paid to insurance companyUSD $262
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedADD
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 CarrierUSD $16,501
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number148510
Policy instance 1
Insurance contract or identification number148510
Number of Individuals Covered70
Insurance policy start date2011-04-01
Insurance policy end date2012-03-31
Total amount of commissions paid to insurance brokerUSD $2,725
Total amount of fees paid to insurance companyUSD $276
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedLIFESTYLE ADD; LIFESTYLE LIFE
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 CarrierUSD $16,902
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number148509
Policy instance 3
Insurance contract or identification number148509
Number of Individuals Covered206
Insurance policy start date2010-05-01
Insurance policy end date2011-03-31
Total amount of commissions paid to insurance brokerUSD $1,864
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $16,137
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 )
Policy contract numberMM308604
Policy instance 1
Insurance contract or identification numberMM308604
Number of Individuals Covered203
Insurance policy start date2010-04-01
Insurance policy end date2011-03-31
Total amount of commissions paid to insurance brokerUSD $184
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $1,316
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number148510
Policy instance 2
Insurance contract or identification number148510
Number of Individuals Covered64
Insurance policy start date2010-06-01
Insurance policy end date2011-03-31
Total amount of commissions paid to insurance brokerUSD $2,115
Total amount of fees paid to insurance companyUSD $0
Are there contracts with allocated funds for individual policies?No
Are there contracts with allocated funds for group deferred annuity?No
Are there contracts with allocated funds for types other than group deferred annuity or individual?No
Contract purchased, in whole or in part, to distribute benefits from a terminating planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedLIFESTYLE ADD; LIFESTYLE LIFE
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 CarrierUSD $12,699
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No

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