MOUNTAIN VIEW HOSPITAL LLC has sponsored the creation of one or more 401k plans.
Submission information for form 5500 for 401k plan MOUNTAIN VIEW HOSPITAL LLC EMPLOYEE BENEFIT PLAN
401k plan membership statisitcs for MOUNTAIN VIEW HOSPITAL LLC EMPLOYEE BENEFIT PLAN
| 2022: MOUNTAIN VIEW HOSPITAL LLC EMPLOYEE BENEFIT PLAN 2022 form 5500 responses |
|---|
| 2022-01-01 | Type of plan entity | Single employer plan |
| 2022-01-01 | Submission has been amended | No |
| 2022-01-01 | This submission is the final filing | No |
| 2022-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2022-01-01 | Plan is a collectively bargained plan | No |
| 2022-01-01 | Plan funding arrangement – Insurance | Yes |
| 2022-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2022-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2022-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2021: MOUNTAIN VIEW HOSPITAL LLC EMPLOYEE BENEFIT PLAN 2021 form 5500 responses |
|---|
| 2021-01-01 | Type of plan entity | Single employer plan |
| 2021-01-01 | Submission has been amended | No |
| 2021-01-01 | This submission is the final filing | No |
| 2021-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2021-01-01 | Plan is a collectively bargained plan | No |
| 2021-01-01 | Plan funding arrangement – Insurance | Yes |
| 2021-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2021-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2021-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2020: MOUNTAIN VIEW HOSPITAL LLC EMPLOYEE BENEFIT PLAN 2020 form 5500 responses |
|---|
| 2020-01-01 | Type of plan entity | Single employer plan |
| 2020-01-01 | Submission has been amended | No |
| 2020-01-01 | This submission is the final filing | No |
| 2020-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2020-01-01 | Plan is a collectively bargained plan | No |
| 2020-01-01 | Plan funding arrangement – Insurance | Yes |
| 2020-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2020-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2020-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2019: MOUNTAIN VIEW HOSPITAL LLC EMPLOYEE BENEFIT PLAN 2019 form 5500 responses |
|---|
| 2019-01-01 | Type of plan entity | Single employer plan |
| 2019-01-01 | Submission has been amended | No |
| 2019-01-01 | This submission is the final filing | No |
| 2019-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2019-01-01 | Plan is a collectively bargained plan | No |
| 2019-01-01 | Plan funding arrangement – Insurance | Yes |
| 2019-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2019-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2019-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2018: MOUNTAIN VIEW HOSPITAL LLC EMPLOYEE BENEFIT PLAN 2018 form 5500 responses |
|---|
| 2018-01-01 | Type of plan entity | Single employer plan |
| 2018-01-01 | Submission has been amended | No |
| 2018-01-01 | This submission is the final filing | No |
| 2018-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2018-01-01 | Plan is a collectively bargained plan | No |
| 2018-01-01 | Plan funding arrangement – Insurance | Yes |
| 2018-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2018-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2018-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2017: MOUNTAIN VIEW HOSPITAL LLC EMPLOYEE BENEFIT PLAN 2017 form 5500 responses |
|---|
| 2017-01-01 | Type of plan entity | Single employer plan |
| 2017-01-01 | Submission has been amended | No |
| 2017-01-01 | This submission is the final filing | No |
| 2017-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2017-01-01 | Plan is a collectively bargained plan | No |
| 2017-01-01 | Plan funding arrangement – Insurance | Yes |
| 2017-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2017-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2017-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2016: MOUNTAIN VIEW HOSPITAL LLC EMPLOYEE BENEFIT PLAN 2016 form 5500 responses |
|---|
| 2016-01-01 | Type of plan entity | Single employer plan |
| 2016-01-01 | Submission has been amended | No |
| 2016-01-01 | This submission is the final filing | No |
| 2016-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2016-01-01 | Plan is a collectively bargained plan | No |
| 2016-01-01 | Plan funding arrangement – Insurance | Yes |
| 2016-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2016-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2016-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2015: MOUNTAIN VIEW HOSPITAL LLC EMPLOYEE BENEFIT PLAN 2015 form 5500 responses |
|---|
| 2015-01-01 | Type of plan entity | Single employer plan |
| 2015-01-01 | Submission has been amended | No |
| 2015-01-01 | This submission is the final filing | No |
| 2015-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2015-01-01 | Plan is a collectively bargained plan | No |
| 2015-01-01 | Plan funding arrangement – Insurance | Yes |
| 2015-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2015-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2015-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2014: MOUNTAIN VIEW HOSPITAL LLC EMPLOYEE BENEFIT PLAN 2014 form 5500 responses |
|---|
| 2014-01-01 | Type of plan entity | Single employer plan |
| 2014-01-01 | Submission has been amended | No |
| 2014-01-01 | This submission is the final filing | No |
| 2014-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2014-01-01 | Plan is a collectively bargained plan | No |
| 2014-01-01 | Plan funding arrangement – Insurance | Yes |
| 2014-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2014-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2014-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2013: MOUNTAIN VIEW HOSPITAL LLC EMPLOYEE BENEFIT PLAN 2013 form 5500 responses |
|---|
| 2013-01-01 | Type of plan entity | Single employer plan |
| 2013-01-01 | Submission has been amended | No |
| 2013-01-01 | This submission is the final filing | No |
| 2013-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2013-01-01 | Plan is a collectively bargained plan | No |
| 2013-01-01 | Plan funding arrangement – Insurance | Yes |
| 2013-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2013-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2013-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2012: MOUNTAIN VIEW HOSPITAL LLC EMPLOYEE BENEFIT PLAN 2012 form 5500 responses |
|---|
| 2012-01-01 | Type of plan entity | Single employer plan |
| 2012-01-01 | Submission has been amended | No |
| 2012-01-01 | This submission is the final filing | No |
| 2012-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2012-01-01 | Plan is a collectively bargained plan | No |
| 2012-01-01 | Plan funding arrangement – Insurance | Yes |
| 2012-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2012-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2012-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2011: MOUNTAIN VIEW HOSPITAL LLC EMPLOYEE BENEFIT PLAN 2011 form 5500 responses |
|---|
| 2011-01-01 | Type of plan entity | Single employer plan |
| 2011-01-01 | Submission has been amended | No |
| 2011-01-01 | This submission is the final filing | No |
| 2011-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2011-01-01 | Plan is a collectively bargained plan | No |
| 2011-01-01 | Plan funding arrangement – Insurance | Yes |
| 2011-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2011-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2011-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2009: MOUNTAIN VIEW HOSPITAL LLC EMPLOYEE BENEFIT PLAN 2009 form 5500 responses |
|---|
| 2009-01-01 | Type of plan entity | Single employer plan |
| 2009-01-01 | Submission has been amended | No |
| 2009-01-01 | This submission is the final filing | No |
| 2009-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2009-01-01 | Plan is a collectively bargained plan | No |
| 2009-01-01 | Plan funding arrangement – Insurance | Yes |
| 2009-01-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2009-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2009-01-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 ) |
| Policy contract number | 0010759838 |
| Policy instance | 3 |
| Insurance contract or identification number | 0010759838 | | Number of Individuals Covered | 124 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $2,226 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $38,446 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $64 | | Insurance broker organization code? | 3 |
|
| WILLAMETTE DENTAL OF IDAHO, INC. (National Association of Insurance Commissioners NAIC id number: 95819 ) |
| Policy contract number | ID239 |
| Policy instance | 8 |
| Insurance contract or identification number | ID239 | | Number of Individuals Covered | 619 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $13,380 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | 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 $13,380 | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL OF IDAHO, INC (National Association of Insurance Commissioners NAIC id number: 47791 ) |
| Policy contract number | 3280 |
| Policy instance | 1 |
| Insurance contract or identification number | 3280 | | Number of Individuals Covered | 1180 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $35,105 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,170,160 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $35,105 | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 632362-0001 |
| Policy instance | 2 |
| Insurance contract or identification number | 632362-0001 | | Number of Individuals Covered | 1073 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $43,154 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ADD | | Welfare Benefit Premiums Paid to Carrier | USD $287,682 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $21,577 | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | R0613315 |
| Policy instance | 4 |
| Insurance contract or identification number | R0613315 | | Number of Individuals Covered | 299 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $4,525 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | GCIEE, GRPACCVO, GRPHSPVO | | Welfare Benefit Premiums Paid to Carrier | USD $96,281 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $942 | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 632361 |
| Policy instance | 5 |
| Insurance contract or identification number | 632361 | | Number of Individuals Covered | 1720 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $16,930 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ADD | | Welfare Benefit Premiums Paid to Carrier | USD $771,372 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,465 | | Insurance broker organization code? | 3 |
|
| AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 ) |
| Policy contract number | AF15-0320-21 |
| Policy instance | 6 |
| Insurance contract or identification number | AF15-0320-21 | | Number of Individuals Covered | 1114 | | Insurance policy start date | 2021-05-01 | | Insurance policy end date | 2022-04-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | 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 number | 649289 |
| Policy instance | 7 |
| Insurance contract or identification number | 649289 | | Number of Individuals Covered | 10 | | Insurance policy start date | 2022-01-01 | | Insurance policy end date | 2022-12-31 | | Total amount of commissions paid to insurance broker | USD $534 | | Total amount of fees paid to insurance company | USD $0 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $3,559 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $534 | | Insurance broker organization code? | 3 |
|
| HCC LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 92711 ) |
| Policy contract number | HCL35612 |
| Policy instance | 6 |
| Insurance contract or identification number | HCL35612 | | Number of Individuals Covered | 1252 | | Insurance policy start date | 2020-05-01 | | Insurance policy end date | 2021-04-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Welfare Benefit Premiums Paid to Carrier | USD $1,466,891 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL OF IDAHO, INC (National Association of Insurance Commissioners NAIC id number: 47791 ) |
| Policy contract number | 3280 |
| Policy instance | 1 |
| Insurance contract or identification number | 3280 | | Number of Individuals Covered | 1043 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $31,823 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $1,023,612 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $31,823 | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 632362-0001 |
| Policy instance | 2 |
| Insurance contract or identification number | 632362-0001 | | Number of Individuals Covered | 807 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $29,130 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ADD | | Welfare Benefit Premiums Paid to Carrier | USD $194,195 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $14,565 | | Insurance broker organization code? | 3 |
|
| PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 ) |
| Policy contract number | 0010759838 |
| Policy instance | 3 |
| Insurance contract or identification number | 0010759838 | | Number of Individuals Covered | 154 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $2,344 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $39,299 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $65 | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | R0613315 |
| Policy instance | 4 |
| Insurance contract or identification number | R0613315 | | Number of Individuals Covered | 383 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $6,723 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | GCIEE, GRPACCVO, GRPHSPVO | | Welfare Benefit Premiums Paid to Carrier | USD $104,979 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $98 | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 632361 |
| Policy instance | 5 |
| Insurance contract or identification number | 632361 | | Number of Individuals Covered | 1282 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $13,006 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ADD | | Welfare Benefit Premiums Paid to Carrier | USD $509,458 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,503 | | Insurance broker organization code? | 3 |
|
| WILLAMETTE DENTAL OF IDAHO, INC. (National Association of Insurance Commissioners NAIC id number: 95819 ) |
| Policy contract number | ID239 |
| Policy instance | 8 |
| Insurance contract or identification number | ID239 | | Number of Individuals Covered | 536 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $8,846 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,846 | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 649289 |
| Policy instance | 7 |
| Insurance contract or identification number | 649289 | | Number of Individuals Covered | 11 | | Insurance policy start date | 2021-01-01 | | Insurance policy end date | 2021-12-31 | | Total amount of commissions paid to insurance broker | USD $1,470 | | Total amount of fees paid to insurance company | USD $0 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $9,801 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,470 | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL OF IDAHO, INC (National Association of Insurance Commissioners NAIC id number: 47791 ) |
| Policy contract number | 3280 |
| Policy instance | 1 |
| Insurance contract or identification number | 3280 | | Number of Individuals Covered | 945 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $26,880 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $896,016 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $26,880 | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 632362 |
| Policy instance | 2 |
| Insurance contract or identification number | 632362 | | Number of Individuals Covered | 722 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $27,734 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ADD | | Welfare Benefit Premiums Paid to Carrier | USD $184,884 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $13,867 | | Insurance broker organization code? | 3 |
|
| PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 ) |
| Policy contract number | 0010759838 |
| Policy instance | 3 |
| Insurance contract or identification number | 0010759838 | | Number of Individuals Covered | 198 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $9,115 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $56,407 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $68 | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 632361 |
| Policy instance | 5 |
| Insurance contract or identification number | 632361 | | Number of Individuals Covered | 1260 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $23,702 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ADD | | Welfare Benefit Premiums Paid to Carrier | USD $529,080 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $11,851 | | Insurance broker organization code? | 3 |
|
| GERBER LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70939 ) |
| Policy contract number | GLIUME002732 |
| Policy instance | 6 |
| Insurance contract or identification number | GLIUME002732 | | Number of Individuals Covered | 2551 | | Insurance policy start date | 2019-05-01 | | Insurance policy end date | 2020-04-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Welfare Benefit Premiums Paid to Carrier | USD $1,133,321 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 649289 |
| Policy instance | 7 |
| Insurance contract or identification number | 649289 | | Number of Individuals Covered | 9 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $508 | | Total amount of fees paid to insurance company | USD $0 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $3,389 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $508 | | Insurance broker organization code? | 3 |
|
| WILLAMETTE DENTAL OF IDAHO, INC. (National Association of Insurance Commissioners NAIC id number: 95819 ) |
| Policy contract number | ID239 |
| Policy instance | 8 |
| Insurance contract or identification number | ID239 | | Number of Individuals Covered | 562 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $10,539 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $10,539 | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | R0613315 |
| Policy instance | 4 |
| Insurance contract or identification number | R0613315 | | Number of Individuals Covered | 470 | | Insurance policy start date | 2020-01-01 | | Insurance policy end date | 2020-12-31 | | Total amount of commissions paid to insurance broker | USD $29,427 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | GCIEE, GRPACCVO, GRPHSPVO | | Welfare Benefit Premiums Paid to Carrier | USD $141,402 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $329 | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL OF IDAHO, INC (National Association of Insurance Commissioners NAIC id number: 47791 ) |
| Policy contract number | 3280 |
| Policy instance | 1 |
| Insurance contract or identification number | 3280 | | Number of Individuals Covered | 719 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $20,806 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $681,348 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $20,806 | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 632362 |
| Policy instance | 2 |
| Insurance contract or identification number | 632362 | | Number of Individuals Covered | 668 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $25,606 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ADD | | Welfare Benefit Premiums Paid to Carrier | USD $171,164 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $12,803 | | Insurance broker organization code? | 3 |
|
| PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 ) |
| Policy contract number | 0010759838 |
| Policy instance | 3 |
| Insurance contract or identification number | 0010759838 | | Number of Individuals Covered | 308 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $20,572 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $57,613 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $65 | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | R0613315 |
| Policy instance | 4 |
| Insurance contract or identification number | R0613315 | | Number of Individuals Covered | 664 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $43,924 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | GCIEE, GRPACCVO, GRPHSPVO | | Welfare Benefit Premiums Paid to Carrier | USD $138,764 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $322 | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 632361 |
| Policy instance | 5 |
| Insurance contract or identification number | 632361 | | Number of Individuals Covered | 1145 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $6,000 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ADD | | Welfare Benefit Premiums Paid to Carrier | USD $421,924 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,000 | | Insurance broker organization code? | 3 |
|
| AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 ) |
| Policy contract number | AFALEG220218 |
| Policy instance | 6 |
| Insurance contract or identification number | AFALEG220218 | | Number of Individuals Covered | 818 | | Insurance policy start date | 2018-05-01 | | Insurance policy end date | 2019-04-30 | | Total amount of commissions paid to insurance broker | USD $43,509 | | Total amount of fees paid to insurance company | USD $0 | | Welfare Benefit Premiums Paid to Carrier | USD $1,247,135 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $43,509 | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 649289 |
| Policy instance | 7 |
| Insurance contract or identification number | 649289 | | Number of Individuals Covered | 6 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $1,186 | | Total amount of fees paid to insurance company | USD $0 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $8,470 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,186 | | Insurance broker organization code? | 3 |
|
| WILLAMETTE DENTAL OF IDAHO, INC. (National Association of Insurance Commissioners NAIC id number: 95819 ) |
| Policy contract number | ID239 |
| Policy instance | 8 |
| Insurance contract or identification number | ID239 | | Number of Individuals Covered | 421 | | Insurance policy start date | 2019-01-01 | | Insurance policy end date | 2019-12-31 | | Total amount of commissions paid to insurance broker | USD $8,311 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $8,311 | | Insurance broker organization code? | 3 |
|
| DELTA DENTAL OF IDAHO, INC (National Association of Insurance Commissioners NAIC id number: 47791 ) |
| Policy contract number | 3280 |
| Policy instance | 1 |
| Insurance contract or identification number | 3280 | | Number of Individuals Covered | 568 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $16,631 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $566,540 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $16,631 | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 632362 |
| Policy instance | 2 |
| Insurance contract or identification number | 632362 | | Number of Individuals Covered | 625 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $25,254 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ADD | | Welfare Benefit Premiums Paid to Carrier | USD $168,361 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $12,627 | | Insurance broker organization code? | 3 |
|
| PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 ) |
| Policy contract number | 0010759838 |
| Policy instance | 3 |
| Insurance contract or identification number | 0010759838 | | Number of Individuals Covered | 333 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $51,074 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $75,872 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $106 | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | R0613315 |
| Policy instance | 4 |
| Insurance contract or identification number | R0613315 | | Number of Individuals Covered | 629 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $80,546 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | GCIEE, GRPACCVO | | Welfare Benefit Premiums Paid to Carrier | USD $166,893 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $588 | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 632361 |
| Policy instance | 5 |
| Insurance contract or identification number | 632361 | | Number of Individuals Covered | 910 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $13,738 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ADD | | Welfare Benefit Premiums Paid to Carrier | USD $380,346 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,869 | | Insurance broker organization code? | 3 |
|
| AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 ) |
| Policy contract number | AFALEG205017 |
| Policy instance | 6 |
| Insurance contract or identification number | AFALEG205017 | | Number of Individuals Covered | 710 | | Insurance policy start date | 2017-05-01 | | Insurance policy end date | 2018-04-30 | | Total amount of commissions paid to insurance broker | USD $51,521 | | Total amount of fees paid to insurance company | USD $0 | | Welfare Benefit Premiums Paid to Carrier | USD $953,068 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $51,521 | | Insurance broker organization code? | 3 |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 649289 |
| Policy instance | 7 |
| Insurance contract or identification number | 649289 | | Number of Individuals Covered | 11 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $759 | | Total amount of fees paid to insurance company | USD $0 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $5,057 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $759 | | Insurance broker organization code? | 3 |
|
| WILLAMETTE DENTAL OF IDAHO, INC. (National Association of Insurance Commissioners NAIC id number: 95819 ) |
| Policy contract number | Z1008/ID239 |
| Policy instance | 8 |
| Insurance contract or identification number | Z1008/ID239 | | Number of Individuals Covered | 422 | | Insurance policy start date | 2018-01-01 | | Insurance policy end date | 2018-12-31 | | Total amount of commissions paid to insurance broker | USD $7,845 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,845 | | Insurance broker organization code? | 3 |
|
| WILLAMETTE DENTAL OF IDAHO, INC. (National Association of Insurance Commissioners NAIC id number: 95819 ) |
| Policy contract number | Z1008/ID239 |
| Policy instance | 9 |
| Insurance contract or identification number | Z1008/ID239 | | Number of Individuals Covered | 316 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $6,175 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,175 | | Insurance broker organization code? | 3 | | Insurance broker name | BLACK INK SOLUTIONS |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 649289 |
| Policy instance | 8 |
| Insurance contract or identification number | 649289 | | Number of Individuals Covered | 9 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $753 | | Total amount of fees paid to insurance company | USD $0 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $5,023 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $753 | | Insurance broker organization code? | 3 | | Insurance broker name | MATTHEW B WALDRAM |
|
| STHEALTH/CHARTIS (National Association of Insurance Commissioners NAIC id number: 77828 ) |
| Policy contract number | |
| Policy instance | 7 |
| Number of Individuals Covered | 580 | | Insurance policy start date | 2016-05-01 | | Insurance policy end date | 2017-04-30 | | Total amount of commissions paid to insurance broker | USD $72,278 | | Total amount of fees paid to insurance company | USD $0 | | Welfare Benefit Premiums Paid to Carrier | USD $728,888 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $72,278 | | Insurance broker organization code? | 3 | | Insurance broker name | BLACK INK BENEFITS |
|
| DELTA DENTAL OF IDAHO, INC (National Association of Insurance Commissioners NAIC id number: 47791 ) |
| Policy contract number | 3280 |
| Policy instance | 1 |
| Insurance contract or identification number | 3280 | | Number of Individuals Covered | 522 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $15,203 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $506,767 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $15,203 | | Insurance broker organization code? | 3 | | Insurance broker name | INTERMOUNTAIN INSURANCE SERVICES |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 632362 |
| Policy instance | 2 |
| Insurance contract or identification number | 632362 | | Number of Individuals Covered | 571 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $24,250 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ADD | | Welfare Benefit Premiums Paid to Carrier | USD $161,660 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $12,125 | | Insurance broker organization code? | 3 | | Insurance broker name | INTERMOUNTAIN INSURANCE SERVICES |
|
| PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 ) |
| Policy contract number | 0010759838 |
| Policy instance | 3 |
| Insurance contract or identification number | 0010759838 | | Number of Individuals Covered | 222 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $25,859 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $31,214 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,213 | | Insurance broker organization code? | 3 | | Insurance broker name | CHARLES D BLOCK |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | R0613315 |
| Policy instance | 4 |
| Insurance contract or identification number | R0613315 | | Number of Individuals Covered | 379 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $49,624 | | Total amount of fees paid to insurance company | USD $0 | | Other welfare benefits provided | GCIEE, GRPACCVO | | Welfare Benefit Premiums Paid to Carrier | USD $82,366 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,297 | | Insurance broker organization code? | 3 | | Insurance broker name | CHARLES D BLOCK |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 53031 ) |
| Policy contract number | 30013918 |
| Policy instance | 5 |
| Insurance contract or identification number | 30013918 | | Number of Individuals Covered | 496 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $3,105 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,105 | | Insurance broker organization code? | 3 | | Insurance broker name | CARLOS APONTE |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 632361 |
| Policy instance | 6 |
| Insurance contract or identification number | 632361 | | Number of Individuals Covered | 863 | | Insurance policy start date | 2017-01-01 | | Insurance policy end date | 2017-12-31 | | Total amount of commissions paid to insurance broker | USD $13,536 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ADD | | Welfare Benefit Premiums Paid to Carrier | USD $291,550 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $6,768 | | Insurance broker organization code? | 3 | | Insurance broker name | INTERMOUNTAIN INSURANCE SERVICES |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 632361 |
| Policy instance | 9 |
| Insurance contract or identification number | 632361 | | Number of Individuals Covered | 534 | | Insurance policy start date | 2015-09-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $4,215 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ADD | | Welfare Benefit Premiums Paid to Carrier | USD $77,671 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $4,215 | | Insurance broker organization code? | 3 | | Insurance broker name | MATTHEW B WALDRAM |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 47783 ) |
| Policy contract number | 30013918 |
| Policy instance | 8 |
| Insurance contract or identification number | 30013918 | | Number of Individuals Covered | 326 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $2,021 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,021 | | Insurance broker organization code? | 3 | | Insurance broker name | BALLARD INSURANCE GROUP LLC |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 230503 |
| Policy instance | 7 |
| Insurance contract or identification number | 230503 | | Number of Individuals Covered | 513 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-08-31 | | Total amount of commissions paid to insurance broker | USD $2,126 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $42,182 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,126 | | Insurance broker organization code? | 3 | | Insurance broker name | CASTLE LAKE INSURANCE LLC |
|
| WILLAMETTE DENTAL OF IDAHO, INC. (National Association of Insurance Commissioners NAIC id number: 95819 ) |
| Policy contract number | Z1008/ID239 |
| Policy instance | 6 |
| Insurance contract or identification number | Z1008/ID239 | | Number of Individuals Covered | 166 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $3,060 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,060 | | Insurance broker organization code? | 3 | | Insurance broker name | BALLARD INSURANCE GROUP LLC |
|
| COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 ) |
| Policy contract number | E4211009 |
| Policy instance | 5 |
| Insurance contract or identification number | E4211009 | | Number of Individuals Covered | 32 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $3,628 | | Total amount of fees paid to insurance company | USD $375 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $16,834 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,798 | | Amount paid for insurance broker fees | 24 | | Additional information about fees paid to insurance broker | OTHER ADMIN FEES | | Insurance broker organization code? | 3 | | Insurance broker name | ZINA OSTER |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 230503 |
| Policy instance | 1 |
| Insurance contract or identification number | 230503 | | Number of Individuals Covered | 513 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-08-31 | | Total amount of commissions paid to insurance broker | USD $2,474 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $85,071 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,474 | | Insurance broker organization code? | 3 | | Insurance broker name | CASTLE LAKE INSURANCE LLC |
|
| DELTA DENTAL OF IDAHO, INC (National Association of Insurance Commissioners NAIC id number: 47791 ) |
| Policy contract number | 3280 |
| Policy instance | 3 |
| Insurance contract or identification number | 3280 | | Number of Individuals Covered | 336 | | Insurance policy start date | 2014-05-01 | | Insurance policy end date | 2015-04-30 | | Total amount of commissions paid to insurance broker | USD $10,203 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $336,070 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $10,203 | | Insurance broker organization code? | 3 | | Insurance broker name | BALLARD INSURANCE GROUP LLC |
|
| STHEALTH/CHARTIS (National Association of Insurance Commissioners NAIC id number: 77828 ) |
| Policy contract number | |
| Policy instance | 10 |
| Number of Individuals Covered | 477 | | Insurance policy start date | 2014-05-01 | | Insurance policy end date | 2015-04-30 | | Total amount of commissions paid to insurance broker | USD $50,922 | | Total amount of fees paid to insurance company | USD $0 | | Welfare Benefit Premiums Paid to Carrier | USD $404,460 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $50,922 | | Insurance broker organization code? | 3 | | Insurance broker name | BLACK INK BENEFITS |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 230503 |
| Policy instance | 2 |
| Insurance contract or identification number | 230503 | | Number of Individuals Covered | 513 | | Insurance policy start date | 2015-01-01 | | Insurance policy end date | 2015-08-31 | | Total amount of commissions paid to insurance broker | USD $3,137 | | Total amount of fees paid to insurance company | USD $0 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $91,496 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,137 | | Insurance broker organization code? | 3 | | Insurance broker name | CASTLE LAKE INSURANCE LLC |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 632362 |
| Policy instance | 4 |
| Insurance contract or identification number | 632362 | | Number of Individuals Covered | 347 | | Insurance policy start date | 2015-09-01 | | Insurance policy end date | 2015-12-31 | | Total amount of commissions paid to insurance broker | USD $2,361 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ADD | | Welfare Benefit Premiums Paid to Carrier | USD $29,482 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,361 | | Insurance broker organization code? | 3 | | Insurance broker name | MATTHEW B WALDRAM |
|
| HCC LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 92711 ) |
| Policy contract number | HCL19680 |
| Policy instance | 8 |
| Insurance contract or identification number | HCL19680 | | Number of Individuals Covered | 394 | | Insurance policy start date | 2013-05-01 | | Insurance policy end date | 2014-04-30 | | Total amount of commissions paid to insurance broker | USD $15,478 | | Total amount of fees paid to insurance company | USD $0 | | Welfare Benefit Premiums Paid to Carrier | USD $309,552 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $15,478 | | Insurance broker organization code? | 3 | | Insurance broker name | ST HEALTH BENEFIT SOLUTIONS, LLC |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 230503 |
| Policy instance | 6 |
| Insurance contract or identification number | 230503 | | Number of Individuals Covered | 473 | | Insurance policy start date | 2013-07-01 | | Insurance policy end date | 2014-06-30 | | Total amount of commissions paid to insurance broker | USD $3,733 | | Total amount of fees paid to insurance company | USD $0 | | Life Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $90,891 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,733 | | Insurance broker organization code? | 3 | | Insurance broker name | CASTLE LAKE INSURANCE LLC |
|
| COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 ) |
| Policy contract number | E4211009 |
| Policy instance | 4 |
| Insurance contract or identification number | E4211009 | | Number of Individuals Covered | 32 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $7,774 | | Total amount of fees paid to insurance company | USD $429 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $19,048 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,145 | | Amount paid for insurance broker fees | 150 | | Additional information about fees paid to insurance broker | OTHER ADMIN FEES | | Insurance broker organization code? | 3 | | Insurance broker name | ZINA OSTER |
|
| DELTA DENTAL OF IDAHO, INC (National Association of Insurance Commissioners NAIC id number: 47791 ) |
| Policy contract number | 3280 |
| Policy instance | 3 |
| Insurance contract or identification number | 3280 | | Number of Individuals Covered | 300 | | Insurance policy start date | 2013-05-01 | | Insurance policy end date | 2014-04-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $265,859 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $7,998 | | Insurance broker organization code? | 3 | | Insurance broker name | BALLARD INSURANCE GROUP LLC |
|
| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 230503 |
| Policy instance | 1 |
| Insurance contract or identification number | 230503 | | Number of Individuals Covered | 473 | | Insurance policy start date | 2013-07-01 | | Insurance policy end date | 2014-06-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $0 | | Temporary Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $52,030 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,414 | | Insurance broker organization code? | 3 | | Insurance broker name | CASTLE LAKE INSURANCE LLC |
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| SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 ) |
| Policy contract number | 230503 |
| Policy instance | 2 |
| Insurance contract or identification number | 230503 | | Number of Individuals Covered | 473 | | Insurance policy start date | 2013-07-01 | | Insurance policy end date | 2014-06-30 | | Long Term Disability Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $112,859 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $5,129 | | Insurance broker organization code? | 3 | | Insurance broker name | CASTLE LAKE INSURANCE LLC |
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| WILLAMETTE DENTAL OF IDAHO, INC. (National Association of Insurance Commissioners NAIC id number: 95819 ) |
| Policy contract number | Z1008/ID239 |
| Policy instance | 5 |
| Insurance contract or identification number | Z1008/ID239 | | Number of Individuals Covered | 185 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $3,425 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,425 | | Insurance broker organization code? | 3 | | Insurance broker name | BALLARD INSURANCE GROUP LLC |
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| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 47783 ) |
| Policy contract number | 30013918 |
| Policy instance | 7 |
| Insurance contract or identification number | 30013918 | | Number of Individuals Covered | 289 | | Insurance policy start date | 2014-01-01 | | Insurance policy end date | 2014-12-31 | | Total amount of commissions paid to insurance broker | USD $1,851 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,851 | | Insurance broker organization code? | 3 | | Insurance broker name | BALLARD INSURANCE GROUP LLC |
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| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 125229 |
| Policy instance | 2 |
| Insurance contract or identification number | 125229 | | Number of Individuals Covered | 438 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $6,472 | | Total amount of fees paid to insurance company | USD $949 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ADD | | Welfare Benefit Premiums Paid to Carrier | USD $109,331 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $2,384 | | Amount paid for insurance broker fees | 949 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | MATTHEW B WALDRAM |
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| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 125230 |
| Policy instance | 1 |
| Insurance contract or identification number | 125230 | | Number of Individuals Covered | 225 | | Insurance policy start date | 2013-05-01 | | Insurance policy end date | 2013-07-01 | | Total amount of commissions paid to insurance broker | USD $1,867 | | Total amount of fees paid to insurance company | USD $77 | | Welfare Benefit Premiums Paid to Carrier | USD $6,138 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $921 | | Amount paid for insurance broker fees | 77 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | MATTHEW B WALDRAM |
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| WILLAMETTE DENTAL OF IDAHO, INC. (National Association of Insurance Commissioners NAIC id number: 95819 ) |
| Policy contract number | Z1008/ID239 |
| Policy instance | 3 |
| Insurance contract or identification number | Z1008/ID239 | | Number of Individuals Covered | 144 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $3,139 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $3,139 | | Insurance broker organization code? | 3 | | Insurance broker name | BALLARD INSURANCE GROUP LLC |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 47783 ) |
| Policy contract number | 30013918 |
| Policy instance | 4 |
| Insurance contract or identification number | 30013918 | | Number of Individuals Covered | 262 | | Insurance policy start date | 2013-01-01 | | Insurance policy end date | 2013-12-31 | | Total amount of commissions paid to insurance broker | USD $1,519 | | Total amount of fees paid to insurance company | USD $118 | | Vision Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,519 | | Amount paid for insurance broker fees | 118 | | Additional information about fees paid to insurance broker | ADDITIONAL COMPENSATION | | Insurance broker organization code? | 3 | | Insurance broker name | BALLARD INSURANCE GROUP LLC |
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| HCC LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 92711 ) |
| Policy contract number | HCL19680 |
| Policy instance | 5 |
| Insurance contract or identification number | HCL19680 | | Number of Individuals Covered | 368 | | Insurance policy start date | 2012-05-01 | | Insurance policy end date | 2013-04-30 | | Total amount of commissions paid to insurance broker | USD $13,651 | | Total amount of fees paid to insurance company | USD $0 | | Welfare Benefit Premiums Paid to Carrier | USD $273,011 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $13,651 | | Insurance broker organization code? | 3 | | Insurance broker name | ST HEALTH BENEFIT SOLUTIONS, LLC |
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| BLUE CROSS OF IDAHO HEALTH SERVICE INC. (National Association of Insurance Commissioners NAIC id number: 60095 ) |
| Policy contract number | 10034453 |
| Policy instance | 2 |
| Insurance contract or identification number | 10034453 | | Number of Individuals Covered | 314 | | Insurance policy start date | 2011-05-01 | | Insurance policy end date | 2012-04-30 | | Total amount of commissions paid to insurance broker | USD $14,156 | | Total amount of fees paid to insurance company | USD $12,500 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $254,993 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $14,156 | | Amount paid for insurance broker fees | 12500 | | Additional information about fees paid to insurance broker | BONUS/OTHER | | Insurance broker organization code? | 3 | | Insurance broker name | BALLARD INSURANCE GROUP LLC |
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| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 47783 ) |
| Policy contract number | 30013918 |
| Policy instance | 3 |
| Insurance contract or identification number | 30013918 | | Number of Individuals Covered | 233 | | Insurance policy start date | 2011-05-01 | | Insurance policy end date | 2012-04-30 | | Total amount of commissions paid to insurance broker | USD $1,273 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | 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 $1,273 | | Insurance broker organization code? | 3 | | Insurance broker name | BALLARD INSURANCE GROUP LLC |
|
| STHEALTH/CHARTIS (National Association of Insurance Commissioners NAIC id number: 77828 ) |
| Policy contract number | |
| Policy instance | 4 |
| Number of Individuals Covered | 292 | | Insurance policy start date | 2011-05-01 | | Insurance policy end date | 2012-04-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $36,590 | | Welfare Benefit Premiums Paid to Carrier | USD $212,242 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 36590 | | Additional information about fees paid to insurance broker | BROKER FEES | | Insurance broker organization code? | 3 | | Insurance broker name | ST HEALTH BENEFIT SOLUTIONS, LLC |
|
| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 125229 |
| Policy instance | 1 |
| Insurance contract or identification number | 125229 | | Insurance policy start date | 2011-05-01 | | Insurance policy end date | 2012-04-30 | | Total amount of commissions paid to insurance broker | USD $10,334 | | Total amount of fees paid to insurance company | USD $1,188 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ADD | | Welfare Benefit Premiums Paid to Carrier | USD $186,155 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $10,334 | | Amount paid for insurance broker fees | 1188 | | Additional information about fees paid to insurance broker | SERVICING FEES | | Insurance broker organization code? | 3 | | Insurance broker name | BALLARD INSURANCE GROUP LLC |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 47783 ) |
| Policy contract number | 30013918 |
| Policy instance | 3 |
| Insurance contract or identification number | 30013918 | | Insurance policy start date | 2011-01-01 | | Insurance policy end date | 2011-12-31 | | Total amount of commissions paid to insurance broker | USD $1,231 | | Total amount of fees paid to insurance company | USD $0 | | Vision Insurance Welfare Benefit | Yes | | 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 number | 125229 |
| Policy instance | 1 |
| Insurance contract or identification number | 125229 | | Number of Individuals Covered | 309 | | Insurance policy start date | 2010-05-01 | | Insurance policy end date | 2011-04-30 | | Total amount of commissions paid to insurance broker | USD $9,539 | | Total amount of fees paid to insurance company | USD $1,532 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | ADD | | Welfare Benefit Premiums Paid to Carrier | USD $153,192 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| DELTA DENTAL OF IDAHO, INC (National Association of Insurance Commissioners NAIC id number: 47791 ) |
| Policy contract number | 2063 |
| Policy instance | 2 |
| Insurance contract or identification number | 2063 | | Number of Individuals Covered | 277 | | Insurance policy start date | 2010-05-01 | | Insurance policy end date | 2011-04-30 | | Total amount of commissions paid to insurance broker | USD $7,415 | | Total amount of fees paid to insurance company | USD $0 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $232,249 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| STHEALTH/CHARTIS (National Association of Insurance Commissioners NAIC id number: 77828 ) |
| Policy contract number | |
| Policy instance | 4 |
| Number of Individuals Covered | 267 | | Insurance policy start date | 2010-05-01 | | Insurance policy end date | 2011-04-30 | | Total amount of commissions paid to insurance broker | USD $0 | | Total amount of fees paid to insurance company | USD $38,200 | | Welfare Benefit Premiums Paid to Carrier | USD $174,560 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No |
|
| PERICO LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85561 ) |
| Policy contract number | 1A |
| Policy instance | 4 |
| Insurance contract or identification number | 1A | | Insurance policy start date | 2009-05-01 | | Insurance policy end date | 2010-04-30 | | Total amount of fees paid to insurance company | USD $35,375 | | Welfare Benefit Premiums Paid to Carrier | USD $143,093 | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Amount paid for insurance broker fees | 35375 | | Additional information about fees paid to insurance broker | BROKER FEES | | Insurance broker organization code? | 3 | | Insurance broker name | BALLARD INSURANCE GROUP LLC |
|
| VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 47783 ) |
| Policy contract number | 30013918 |
| Policy instance | 3 |
| Insurance contract or identification number | 30013918 | | Number of Individuals Covered | 201 | | Insurance policy start date | 2010-01-01 | | Insurance policy end date | 2010-12-31 | | Total amount of commissions paid to insurance broker | USD $1,227 | | Vision Insurance Welfare Benefit | Yes | | Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500? | No | | Commission paid to Insurance Broker | USD $1,227 | | Insurance broker name | BALLARD INSURANCE GROUP LLC |
|
| DELTA DENTAL OF IDAHO, INC (National Association of Insurance Commissioners NAIC id number: 47791 ) |
| Policy contract number | 2063 |
| Policy instance | 2 |
| Insurance contract or identification number | 2063 | | Number of Individuals Covered | 255 | | Insurance policy start date | 2009-05-01 | | Insurance policy end date | 2010-04-30 | | Total amount of commissions paid to insurance broker | USD $5,707 | | Dental Insurance Welfare Benefit | Yes | | Welfare Benefit Premiums Paid to Carrier | USD $170,464 | | Commission paid to Insurance Broker | USD $5,707 | | Insurance broker organization code? | 3 | | Insurance broker name | BALLARD INSURANCE GROUP LLC |
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| UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 ) |
| Policy contract number | 125229 |
| Policy instance | 1 |
| Insurance contract or identification number | 125229 | | Number of Individuals Covered | 266 | | Insurance policy start date | 2009-05-01 | | Insurance policy end date | 2010-04-30 | | Total amount of commissions paid to insurance broker | USD $9,165 | | Total amount of fees paid to insurance company | USD $1,407 | | Life Insurance Welfare Benefit | Yes | | Temporary Disability Insurance Welfare Benefit | Yes | | Long Term Disability Insurance Welfare Benefit | Yes | | Other welfare benefits provided | VOL LIFE, VOL DEP LIFE | | Welfare Benefit Premiums Paid to Carrier | USD $125,371 | | Commission paid to Insurance Broker | USD $9,165 | | Amount paid for insurance broker fees | 1407 | | Additional information about fees paid to insurance broker | SERVICING FEES | | Insurance broker organization code? | 3 | | Insurance broker name | BALLARD INSURANCE GROUP LLC |
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